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THE UNIVERSITY | 
OF ILLINOIS i 
LIBRARY _ | 


From the library of 
Dr. Charles B. Johnson 
Champaign | 
Presented by 
Alice S. Johnson, '07 
1933 


o\o.D 
Bolin 





books. 
University of Illinois Library 


APR 28 1959 


M32—30715 








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Joe 


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BY THE SAME AUTHOR. 


EczEMA AND ITS MANAGEMENT, a practical treatise based on 
the study of two thousand five hundred cases of the disease, pp. 344. 
$3.00. : 

NEUMANN’S HANDBOOK OF SKIN DISEASES, translated with 
notes, pp. 467. $4.00. 

ARCHIVES OF DERMATOLOGY, a Quarterly Journal of Skin and 
Venereal Diseases. Vol. I. to VIII. (current.) Vol. I.-IV., $3 per 
year ; Vol. V. to VIII., $4 per year. 

Tue Skin IN HEALTH AND DisEAseE. Health Primer, pp. 148. 
Fifty cents. : 

THE USE AND VALUE OF ARSENIC IN THE TREATMENT OF 

DISEASES OF THE SKIN. Fifty cents. 


In Preparation. 


PRINCIPLES AND PRACTICE OF DERMATOLOGY: A theoretical 
and practical treatise on Diseases of the Skin, 8vo. 


NEN EIACTS 


OF 


DISEASES OF THE SKIN 


WITH 


AN ANALYSIS OF EIGHT THOUSAND 
CONSECUTIVE CASES 


AND 


A FORMULARY 


BY 


L. DUNCAN BULKLEY, A.M., M.D. 


ATTENDING PHYSICIAN FOR SKIN AND VENEREAL DISEASES AT THE NEW YORK HOS- 
PITAL, OUT-PATIENT DEPARTMENT ; DERMATOLOGIST TO THE HOSPITAL FOR 
RUPTURED AND CRIPPLED } LATE PHYSICIAN TO THE SKIN DEPART- 

MENT, DEMILT DISPENSARY, NEW YORK 3} AUTHOR OF ‘* ECZEMA 

AND ITS MANAGEMENT ”’ } EDITOR OF THE ‘‘ ARCHIVES OF 
DERMATOLOGY ”’? ; PERMANENT MEMBER OF THE 
AMERICAN MEDICAL ASSOCIATION } FEL- 
LOW OF THE NEW YORK ACADEMY 
OF MEDICINE, ETC., ETC, 


NEW YORK 
Ge beets plea ys ON Sr 
27 AND 29 WEST 23D STREET 
1882 


CopyRIGHT, 
1882, 
By G. P. PUTNAM’S SONS. 


Soh 
JO 4) 7) £O0r) 


Nit SL iy Miss Alice 


REMOTE STORAGE 


TO 
THE GOVERNORS 


OF THE 


NEW YORK HOSPITAL, 


WHOSE KIND APPRECIATION AND ASSISTANCE OF THE 
AUTHOR IN HIS CLINICAL WORK IN THEIR INSTITU- 
TION HAVE. DONE MUCH TO ENCOURAGE HIM 
AND TO PROMOTE THE {NTEREST OF 
THE PROFESSION IN THE 
BRANCH OF 


DERMATOLOGY, 


THIS LITTLE WORK IS INSCRIBED. 


> NN 


MLA ae ‘2 
Pe Dah > ye. ; 
Gh pees: 


a 





PREPAGH, 


THE following pages represent an attempt to pre- 
sent the subject of Diseases of the Skin concisely, 
and yet with sufficient details to be of practical 
value to the student and practitioner. They are 
offered as an introduction to the study of a branch 
which is of great importance, and yet which is not 
readily grasped, owing to many reasons, such as the 
large number and variety of affections of the skin, 
their difficulty of recognition and the confused and 
unwieldy nomenclature often employed. 

The present little work has been largely prepared 
for those following my clinics at the New York 
Hospital, and has indeed grown out of a Skin Phar- 
macopeeia arranged for their use. The aim has 
been to make it thoroughly practical, and it par- 
takes much of the style of class room conversations 
upon the various diseases as they appear clinically. 
Pathology is introduced but briefly, and no attempt 
has been made to enter the literature of the subject, 
or to present or discuss doubtful questions. Differ- 
ential diagnosis has not been fully entered on, for 
want of space, but in connection with each erup- 


tion mention is made of those with which it may 
Vv 


ee PREFACE. 
be confounded. In order to present the relative 
frequency and importance of different affections in 
the briefest space possible, a chapter is devoted to 
the analysis of eight thousand skin cases. 

The nomenclature and classification employed 
correspond in the main to those used by many; 
the nomenclature being Latin, and the diseases be- 
ing mostly grouped on a pathological basis. In this, 
as in other matters, the desire has been not to pre- 
sent new or startling features, but to harmonize, 
as far as possible, the views of dermatologists in 
various countries. It is hoped that the very com- 
plete index will be of much service. 

The matter of therapeutics has been dwelt on 
more largely than might be expected in a small 
“manual’’; it is hoped, however, that this, with the 
‘“ formulary,’ may be of a practical value to the prac- 
titioner, while they serve as a guide to the student in 
becoming acquainted with remedies. While this 
portion represents to a certain degree the treatment 
recommended by others, the actual application of 
remedies refers rather to their employment in my 
own practice. 

Acknowledgment is here made of aid derived from 
the writings of Hebra, Kaposi, Neumann, Duhring, 
Piffard, Wilson, Fox, Anderson, Hardy, and others, 
to the study of whose works it is hoped that the 
present may be a further incitement. 


1 East 33RD STREET, NEw York City. 


CONTENTS. 





CHAPTER I. 


PAGE 

Or tie-ocuay of Dermatology. c.s. ofa asc rictis webaesesiee ees I 
CHAPTER II. 

Anatomy and Physiology of the lcin eros. aeons wie asses « 5 
CHAPTLERSITE 

Nomenclature and Classification of Diseases of the Skin...... 18 
CHAPTER. IV. 

Relative Frequency of Diseases of the Skin: Statistics of Eight 

MT OUUSA MI CASES aie po ede il eave here ree taal iherome eer re eeentens, oP 25 
CHAPTER V. 

PAG TOSIS EIU een funk? tiedin oes is Le Sits ea ataiel aos, 0S nein Gate + 4 vets 32 
CHAPTER VL 

MUO OOM ee conga se bhe a! Wrrclist wis @iae ele gstdpo Whe Sere n,0 ss a-nae aee Roaryts 42 


GHAPTER VII. 
Class I. Morbi Cutis Parasitici— Vegetable Parasitic Affections 46 


CHAPTER VIII. 
Class I. Morbi Cutis Parasitici—Animal Parasitic Affections 
WOCTEIN CCL) ater Wee, ae eta eae: asia alg tise oe thus eg ty ae 63 - 
CHAPTER IX. 
Class II. Morbi Glandularum Cutis—Glandular Affections.... 73 


CHAPTER X. 
Class LiTs Neuroses—-Neurotic Affections.:... 4... ¢iteceupes go 


Vill | CONTENTS. 


CHAPTER XI. 


Class IV. Exsudationes—Exudative or Inflammatory Affections 101 


CHAPTER XII. 
Class IV. Exsudationes—Exudative or Inflammatory Affec- 
tions (CONTINUE): cile, sst.sel seater era aie eta ake eeetehcr: = een II7 
CHAPTER XIII. 
Class IV. Exsudationes—Exudative or Inflammatory Affec- 
tions (continued)—of Internal or Local Origin............. 138 
CHAPTER XIV. 
Class IV. Exsudationes—Exudative or Inflammatory Affec- 


tions (continued) & 33. c.< ccm teites ae oa eee iota eee 164 


CHAPTER XV. 
Class IV. Exsudationes—Exudative or Inflammatory Affec- 


tions (continued)......... Cg Ag eens eee dain’ Cuma. 193 

CHAPTER XVI. 

Class V. Hemorrhagie—Hemorrhagic Affections...........- 209 
CHAPTER XVII. 

Class VI. Hypertrophie—Hypertrophic Affections........... 212 
CHAPTER XVIII. 

Class VII. Atrophize—Atrophic Affections..... Referee © sent 235 


CHAPTER XIX. 
Class VIII. Neoplasmata—New Formations................-. 245 


: CHAPTER XX. 
Diet-and Aiygiene of Diséases of the SKinw ets... t bales im 267 


CHAPTER XXII. 
Mherapeutics of Wiseases’ of ihe Skin. .-iye0.., «ae eee pee 295 


MANUAL 


OF 


Reise AS bs, OF PEPE Ski PN: 


GEA bE Kael: 
ON THE STUDY OF DERMATOLOGY. 


WHILE it is not possible for every one to become 
proficient to the highest attainable degree in every 
branch of medical practice, there is no reason why 
all who enter the profession should not acquire a 
fair knowledge concerning the diseases which affect 
the integument. There are indeed many reasons 
why accuracy should be cultivated in this rather 
than in many other departments of medicine; and 
it may be fairly said that he who understands the 
branch of diseases of the skin well, is better fitted 
for general practice than he who is master of any 
other one specialty. 

Dermatology is an especially inviting field, be- 
cause all the lesions of disease are exposed to view, 
and pathological changes can be studied on the skin 


as nowhere else in the body. Here inflammation 
I 


2 MANUAL OF DISEASES OF THE SKIN. | 


and its processes and products can be watched while 
taking place; hypertrophy and atrophy occur here 
in their fullest extent; and these, with new forma- 
tions, constitute the richest field of pathological 
_ research, both in their gross features, and in their 
histological elements. And finally the study of 
‘vegetable parasites as they affect the integument 
has led to researches in other fields of pathology. 

But, again, dermatology is inviting because there 
is no branch of medicine, surgery not excepted, 
where accuracy of diagnosis can be obtained more 
surely and in a larger percentage of cases than in 
that of affections of the skin. In no class of dis- 
eases, moreover, are the results of treatment so 
plainly visible; the ill effects of wrong measures are 
at once seen, and the benefits from proper treat- 
ment are no less apparent, both to the patient and 
physician. 

The study of dermatology, therefore, is not to be 
underrated because so many of the diseases com- 
ing under its domain do not endanger life, and are 
found in those in apparently excellent health. For 
not only do disorders which may appear to be in- 
significant cause much distress to those affected, but 
not a few of the diseases of the integument are 
‘very important from their bearing upon the general 
health and usefulness both of the sufferer and of 
others. As illustrations of this last assertion may be 
mentioned the relations of certain diseases of the 


ON THE STUDY OF DERMATOLOGY. 3 


skin to the gouty state, of which they are often pre- 
cursory signs; also, the parasitic affections, which 
may sometimes spread through an entire school or 
community from carelessness; and, above all, the 
great importance of early recognizing every mani- 
festation of syphilis should be borne in mind, both 
for the welfare of the patient and as a preventive 
of the spread of the disease to others. It must 
further be remembered that many diseases not al- 
ways reckoned as belonging to the province of der- 
matology, such as small-pox, scarlet fever, measles, 
erysipelas, and others, exhibit skin phenomena 
which may at times be difficult of diagnosis, and 
may be closely simulated by quite different affec- 
tions of the skin. 

The relations of dermatology, therefore, to the 
practice of general medicine are most intimate and 
important, and a clear understanding of this branch 
is essential for general success. The close observa- 
tion and the appreciation of minute features which 
are called for in the study of diseases of the skin, 
are also elements in medical practice the cultivation 
of which cannot be too strongly insisted upon ; 
while the effect of remedies, external and internal, 
which can be clearly observed in the treatment of 
these diseases, teaches much in regard to the thera- 
peutics of diseases of other organs. 

The error has often occurred of isolating derma- 
tology too much from the ordinary practice of 


4 MANUAL OF DISEASES OF THE SKIN.’ 


medicine, and of regarding it as a department quite 
separate, and one difficult to understand and grasp; 
whereas, in point of fact, this branch cannot be 
rightly understood except by those thoroughly ac- 
quainted, theoretically and practically, with medi- 
cine as awhole. Skin diseases are not separate and 
distinct affairs, having relations and conditions quite 
different from those affecting other portions of the 
body, but must be studied on the same principles 
as diseases of other organs. They depend largely 
upon the same class of causes, and many of them 
resemble other maladies very closely; almost all of 
them have relations reaching further than the skin 
itself. With this view or thought in mind, we will 
briefly enter upon the study of the subject. 


Chis rae og Be a 
ANATOMY AND PHYSIOLOGY OF THE SKIN. 


THE skin is the largest, and in some respects the 
most important emunctory organ of the body, and 
upon a proper performance of its functions depends, 
to a great extent, the health and well-being of the 
individual. While its apparent purpose is merely 
as an outer investment, for the object of giving 
shape and symmetry to the human form, and of 
enabling it to resist external agencies which would 
injure or destroy more delicate structures, it has 
also functions of its own to perform which are most 
important. It furnishes the means of exhaling a 
large proportion of the fluid given off from the 
body, and is the chief means for maintaining ani- ~ 
mal heat at an equable point. 

To fulfill its many duties, the skin is composed of 
a number of different elements, all united in a har- 
monious texture; it contains excretory glands and 
organs of sensation, and has, as appendages, the 
hair and nails, all to serve definite purposes. In 
certain localities it undergoes changes in structure 
according to the necessities of the case; thus on 
the palms, soles, and buttocks it is thick and re- 

5 


6 MANUAL OF DISEASES OF THE SKIN, 


sisting; while it is thin and delicate on the eyelids, 
penis, and certain other regions. On the scalp, face, 
and elsewhere it produces hairs, which are but modifi- 
cations of its epithelial elements; and on the ends 
of the fingers and toes, another variation in epider- 
mal development gives rise to the nails. At the 
orifices of the body, as at the nose, mouth, urethra, 
vulva, and anus, its anatomy is altered to conform 
to the requirements of the parts, and the mucous 
membranes result, which are indeed but altered 
skin, whose diseases are often closely allied to or 
connected with those of the outward integument. 
The skin is composed in the main of two layers, 
quite different in their structure and composition. 
The lower or deeper one is called the corzum, cutzs 
vera, true skin, or derma, and the outer one is named 
the epzdermis (Greek, epi, upon, and derma, skin). 
The derma or corium, the inner or deeper portion, 
which constitutes the leather of commerce, is com- 
posed of densely interwoven connective tissue fibres, 
firm and elastic, which interlace and form a texture 
resembling felt. At the deepest part of this corium 
or true skin, the fibres are separated, and between 
them are found masses of fat globules, constituting 
the panniculus adiposus, or adipose tissue; in the outer 
portion the fibres are closely matted together, and 
the surface externally rises into minute prominences, 
called the papillz of the skin, this portion having 
the name of the papillary layer, or pars papillarts. 


ANATOMY AND PHYSIOLOGY OF THE SKIN. 7 


The epidermis, cuticle, or scarf skin, has no fibres, 
but is composed of roundish elements called cells. 
The deeper cells are more rounded or many-sided, and 
succulent, and compose what is known as the rete 
mucosum or rete Malpighit, this rests directly upon the 
papilla, and dips down into the interstices between 
them. In the cells of this deepest layer is found 
the pigment or coloring matter, normally in the’ 
colored races and in certain regions of the white 
body, as about the areole of the breasts and else- 
where; it also occurs in this layer pathologically in 
certain diseased states, hence the difficulty of re- 
moving pigmentary deposits in the skin. The outer 
layers of cells of the epidermis are more flat, and as 
they approach the exterior they become still more 
flattened, hardened, and lifeless, only waiting to be 
thrown off or removed by friction. 

The corium, or true skin, contains a number of 
elements which demand closer consideration. These 
are blood-vessels, nerves, lymphatics, muscular fi- 
bres, hair follicles, sebaceous glands, sweat glands, 
_ and nails. 

The blood and nerve supply of the skin is ex- 
ceedingly abundant, and is of the utmost impor- 
tance in its relations to its diseases. Its very great 
richness in these elements may be judged from 
the fact, that even a fine needle cannot be intro- 
duced into the skin without drawing blood and 
causing pain. The blood-vessels coming from be- 


8 MANUAL OF DISEASES OF THE SKIN, | 


low anastomose very freely in the skin and rise into 
the papillee. 

The nerves of the skin serve the purposes of pre- 
siding over its nutrition, of providing general sensa- 
tion which shall protect the parts from injury, and 
of furnishing the sense of touch. In the main the 
larger nerves are confined to the corium, but nerve 
elements have been also traced beyond the true skin 
even into the second or third layer of cells of the rete 
Malpighii; also in the sheaths of the hair follicles, - 
and in the sebaceous glands. Within the papille 
are found what is known as the ¢actzle corpuscles ; 
these consist of a mass of nucleated cells, mingled 
with connective tissue, into which the medullated 
nerve fibre is seen to run and apparently to termi- 
nate. It is thought that in them lies the sense of 
touch. The nerves which preside over nutrition, 
the ¢rophic nerves, have not yet been demonstrated, 
and very little is also known with regard to the 
vaso-motor nerves in the skin; but that both these 
are exceedingly important in their relations to skin 
diseases cannot be doubted, from the structural 
changes, the functional glandular derangements, 
and also the congestion and inflammation which oc- 
cur so readily in the integument. 

The lymphatics of the skin are very numerous, and 
undoubtedly of importance in connection with its 
pathology. They have been recently demonstrated 
to be very abundant, both throughout the skin and 


ANATOMY AND PHYSIOLOGY. OF THE SKIN. 9 


in connection with the sebaceous and sweat glands 
and the hair follicles. As yet we know little of their 
real relations to the diseases of the skin, although 
in certain affections, as elephantiasis, morphea, 
- lymphangioma, erysipelas and others, they proba- 
bly play an important part. We see the lymphatic 
element exhibited in the multiple adenopathy of 
syphilis; also in the buboes connected- with chan- 
croids, and the milder glandular swellings accom- 
panying prurigo and also inflammatory conditions 
on the lower extremities; likewise in the enlarged 
glands in the back of the neck, in pustular eczema 
and other diseases of the scalp. 

Muscular fibres exist in the skin in two forms 
or conditions. First, there is a small amount of 
smooth muscular tissue running horizontally, which 
is more developed in certain localities than in others. 
In some animals there is a considerable amount of 
striated or voluntary muscular fibre throughout the 
entire skin, whereby they are able to move it to a 
slight degree, and thus to assist in shaking off dust, 
insects, etc.; the dartos of the scrotum somewhat 
resembles this, but here the movements are almost, if 
not quite, entirely involuntary, and these frequently 
interfere materially with the treatment of eczema 
in this region. The greatest development of the 
muscular fibre in the skin of man is found in the sec- 
ond form of distribution, in connection with the seba- 


ceous glands and hair follicles, next to be described. 
I* 


10 MANUAL OF DISEASES OF THE SKIN. 


Hair and hair follicles.—The relations of the 
hair follicles to the integument can be best under- 
stood by imagining the lower or fibrous portion of 
the skin to be soft and plastic, and the upper or 
epidermal layers to be pushed down into it without 
breaking, around a penetrating hair; the sheaths 
of the hair are thus seen to be cellular, and toa 
certain extent to correspond to the layers in the epi- 
dermis. Quite a number of separate layers of cells 
have been made out and described, but the practi- 
cal point to be remembered is, that they are cellu- 
lar, reaching down into a fibrous structure; this 
will be found to be of importance in reference to 
the vegetable parasitic diseases. At the bottom 
of the hair follicle thus formed, which in the case 
of larger hairs extends through the extreme thick- 
ness of the skin, the fibrous elements of the corium 
rise and form what is known as the hazr papilla, 
from which the hair is supposed to take its growth. 
This contains blood-vessels and extends up into, and 
is embraced by the lower portion of the hair. The 
hair itself is composed, like the epidermis, of cells; 
at its deepest portion, within the follicle, these cells 
are seen to be quite round or polygonal, and are soft 
and succulent like those of the rete Malpirhii. Those 
further outward are more flat and compressed, until 
finally all the cells are so flattened and condensed 
together that they appear like fibres, and these con- 
stitute the entire length of the hair, however great. 


ANATOMY AND PHYSIOLOGY OF THE SKIN. {1 


Hairs exist over almost every portion of the sur- 
face of the body, with a few exceptions, as in the 
palms and soles, the internal surface of the prepuce, 
and the glans penis, though in some situations they 
are so fine as to be hardly discernible with the na- 
ked eye. The number of the hairs is exceedingly 
great, varying vastly in different individuals. Be- 
tween seven and eight hundred have been counted 
on a square inch, and the total number on the scalp 
has been estimated at between ninety and one hun- 
dred and twenty thousand. Hair is very strong, 
and yet very elastic; a single hair has supported a 
weight of over two ounces, although such strength 
is undoubtedly exceptional; repeated instances have 
occurred where the scalp has been torn from the 
head by means of the hair, so firmly is it attached, 
and yet in disease it may fall with the slightest 
touch or break with the gentlest traction. Hair is 
so very elastic that it may stretch almost one third 
of its length, and regain its former dimensions. 

Sebaceous or sebiparous glands.—These are irregu- 
larly shaped masses of glandular structure, belong- 
ing to the variety known as racemose glands, and 
with a single excretory duct; they are almost in- 
variably connected with hairs of some size. Upon 
hairy parts, as the scalp, they form appendages to 
the hairs, and discharge their secretion into the hair 
follicles. Generally there are two to each hair, situ- 
ated on opposite sides; but in some situations large 


12 MANUAL OF DISEASES OF THE SKIN. 


hairs have a number, even from four to eight, situ- 
ated around them, forming a sort of collar about 
the hair. In other places, where the hairs are fine 
and rudimentary, the sebaceous glands are large, 
and the tiny hair appears there as an appendage to 
a comparatively large gland. All the sebaceous 
glands, however, are very minute affairs, and mostly 
situated in the outer portion of the corium. The 
secretion from these glands is of an oily nature, and 
when ina healthy condition, it is perfectly fluid at 
the temperature of the body. The quantity of the 
secretion is not very great in health, and its main 
function appears to be to keep the skin and hairs 
ina flexible state; although the amount of solid 
matter thrown off thus must be of some importance 
in the economy. When these glands fail to act, we 
have a dry harsh condition of the skin, known as 
xeroderma; and when the secretion becomes blocked, 
it forms comedo, both of which states will be treated 
of in connection with acne. Sometimes the secre- 
tion is great, and appears as an oily coating on the 
skin; or it may dry, forming coarse scales or greasy 
crusts, representing seborrhcea or acne sebacea. 
Neither of these conditions in which the secretion is 
observed represents the normal state of the seba- 
ceous material. 

The muscles of the skin, which are connected with 
the hair follicles and sebaceous glands, the arrec- 
tores pilorum, play a part which it is important to 


ANATOMY AND PHYSIOLOGY OF ‘THE SKIN. Lae 


understand. These are attached to the lowest por- 
tion of the hair follicle, and, running diagonally, 
are inserted in the upper portion of the corium; 
they thus embrace the sebaceous glands connected 
with the hairs, so that each time they contract, 
pressure is made upon the glands, and their con- 
tents more or less forced out. On the parts of the 
body, such as the face, back, and chest, where the 
sebaceous glands are very large and the hairs very 
insignificant, the glands lose this aid to the expul- 
sion of their secretion and very readily become 
clogged, thus furnishing one of the reasons for the 
prevalence of acne upon these parts. When these 
muscles contract under the influence of cold or men- 
tal emotions, the surface presents minute transitory 
elevations, cutzs anserina, or “ goose skin;” this may 
be produced at will on entering a bath, by allow- 
ing the exposed surface to become a little chilled, 
while dry, when the hairs are seen to become 
erected, especially on the arms. 

Sweat or sudortparous glands.—These are in the 
form of minute tubes, which are coiled up in the 
deepest portion of the corium, or even in the subcu- 
taneous adipose tissue, and then extending through 
the entire thickness of the skin, and after making 
several spiral turns within the epidermal portion, they 
open directly upon the outer surface. These glands 
are very numerous in some portions; on the sole of 
_ the foot and palm of the hand there are about 2700 


* 


14. MANUAL OF DISEASES OF THE SKIN. 


in the square inch; on the legs there are about 550 
in the same space, and on the forehead about 1250. 
According to careful computation their total num- 
ber amounts to almost 2,400,000; the total length 
of all of these minute tubes when uncoiled has been 
variously estimated at from two to eight miles. 

The action of these little glands is not intermit- 
tent but continuous, and sweat is incessantly exhaled 
in the form of vapor or zusensible perspiration. It is 
only when the body becomes much heated, as by 
exercise or otherwise, or in disease, that the per- 
spiration manifests itself to the eye or touch. The 
total quantity of the fluid exhaled by the skin is 
subject to the greatest variations, according to tem- 
perature, moisture, exercise, quantity and quality of 
food and drink taken, etc. The average person in 
health gives off through the skin ordinarily be- 
tween one and two pounds or pints of fluid daily, 
a quantity almost equal to that excreted by the kid- 
neys. When animals are completely covered with 
an impermeable coating, as by varnishing the sur- 
face, death always takes place; and the story is 
current among physiologists, that a child who was 
covered with gold leaf in order to represent an 
angel in the ceremonies attending the coronation 
of Pope Leo X., died a few hours after the coating 


_ had been applied. 


Natls.—The nails resemble the hairs very closely 
in many respects, and are but altered portions of the 


ANATOMY AND PHYSIOLOGY OF THE SKIN. 15 


epidermis. We speak of the root and the body of 
the nail, the voot being that portion toward the 
trunk, and situated beneath the skin. The Jody of 
the nail, which represents the section of the hair 
within the follicle, is the remaining attached por- 
tion, while the free extremity of the nail, which 
custom and convenience remove frequently, corre- 
sponds.to. the free extremity. ofthe hair. The 
matrix of the nail is that upon which the nail rests, 
and to which it is firmly attached. Nails grow from 
their roots just as do the hairs, and only slide over 
their matrix or bed, so that injuries to the matrix 
need not cause a disfigured nail, other than of the 
portion directly injured, whereas injury or disease 
at its root will generally cause a destroyed or de- 
formed nail. 


PHYSIOLOGY OF THE SKIN. 


The physiology of the skin is important to re- 
member, both in its relations to dermatology and to 
general medicine. Asa great emunctory organ, it 
shares very largely with the lungs and kidneys the 
office of removing the superfluous water from the 
system. The skin and kidneys each excrete some. 
where between one and two pounds of liquid daily, 
while the lungs, perhaps, not over one half or two 
thirds as much. It can be readily understood, there- 
fore, how ‘‘a check of perspiration” can act harm- 


16 MANUAL OF DISEASES OF THE SKIN. 


fully by throwing extra work upon other organs. 
These three great agents for removing or eliminat- 
ing water from the system act in harmony, and in- 
terchange their duties to a greater or less degree. 
Thus, in cold weather, when the skin perspires less, 
‘the kidneys are more active, as are also the lungs; 
in summer, again, when the perspiration may be pro- 
fuse, it is a common observation to find the urine 
more scanty. This vicarious action of these organs 
is frequently taken advantage of in medicine, as 
when, in kidney disease, we cause the skin to act 
profusely and remove water which threatens dropsy ; 
also in pneumonia, where power for work of the 
lungs is seriously impaired, the action of the skin 
is excited in like manner. Again, in many diseases 
of the skin great advantage results from remedies 
which increase the action of the kidneys and bowels. 

The results of physiological research show that 
very considerable impression may be made upon 
the general system by simply acting upon the skin, 
as by baths, the cold pack, etc.; advantage may 
often be taken thus of the absorbing power of the 
skin for the introduction of remedies through this 
channel, and nutrition also may be greatly affected 
by fatty inunctions. Failure in the action of the kid- 
neys, bowels, lungs, and liver, deranges the balance 
of the system, and may result in disease of any 
organ which has work thrown upon it which it 
‘cannot perform; we must believe, therefore, that 


ANATOMY AND PHYSIOLOGY OF THE SKIN. EZ 


the skin undoubtedly may become diseased in the 
effort to produce its secretions from imperfectly 
elaborated blood, as well as from attempting to 
take its nourishment from that which has been 
insufficiently prepared in other portions of the 
economy. 

The beneficial effects often aheeived in skin dis- 
eases from the use of mineral waters in bathing and 
drinking, must not be attributed to their action upon 
the diseased tissues alone; the skin as an organ is 
often affected favorably, and performs its work 
better, and the kidneys and bowels are stimulated 
to action by the mineral ingredients. Even when 
used externally alone, other organs are more or less 
influenced by the mineral water, as it has been 
definitely shown that the urine can be affected, 
both in its liquid and solid elements, by means of 
baths and wet packs. 


GHAP IER si 


NOMENCLATURE AND CLASSIFICATION OF DISEASES 
OF THE ,SKIN. ; 


= 


VERY much confusion, and much of the difficulty 
attending the study of dermatology, has resulted 
from the number and variety of terms which have 
been applied to these diseases, by different authors. 
Many affections have been called by quite different 
names, and often the same designation has been 
given to diseases which are quite distinct ; not only 
has every author or teacher felt at liberty to coin 
new terms, or to propose changes, but in some in- 
stances they have not even faithfully adhered to 
one namé, but have made repeated changes, both 
in those employed by themselves and others. 

Happily at the present time this error of past 
study is appreciated by the majority of those who 
write and teach this branch, and the desire is becom- 
ing more and more fixed and manifest to use der- 
matological names that are not only plain, but such 
as can be adhered to by those of every nation and 
school. It would be useless to attempt to enter 
upon, much more to give severally, the various 
views which have been promulgated in times past, 


CLASSIFICA TION OF DISEASES OF THE SKIN. Ig 


and the different names and systems which have been 
put forward, only to last until the death of their 
producer, or not to find acceptance beyond his im- 
mediate circle: The dermatology of to-day looks 
back upon the heaps which have been piled up, only 
to endeavor to avoid the repetition of such follies ; 
and all who have this branch deeply at heart, are 
seeking for unity of thought on this subject. 

Inasmuch as different names may be given to dif- 
ferent diseases in various countries, the Latin lan- 
guage has become more and more adopted for the 
expression of exact science; and in order that many 
of the names which have been used and known from 
antiquity may not be changed, the older Greek 
terms are retained as far as possible, while the Latin 
is further used for secondary names and expletives. 
The following of this plan in various countries, to- 
gether with the publication of photographic and 
other representations of diseases, will soon har- 
monize dermatological thought, and render the 
study of cutaneous maladies much more easy. 

The classification of diseases of the skin, while 
not of the utmost importance, still often serves as 
an aid to the understanding of the branch. Vari- 
ous efforts have been made at forming a clinical 
classification; but the plans have varied so much, 
according to the views of the writer, that no two 
have very greatly resembled each other, and few 
authors have quite agreed upon the subject. With 


20 MANUAL OF DISEASES OF THE SKIN. 


the study of pathological anatomy, however, dis- 
eases of the skin, as well as those of other organs, 
have come to be placed in certain groups according 
to the pathological changes which have taken place. 
In a very rough way, this was first proposed many 
years ago by Plenck, and followed by Willan and 
others, who divided skin diseases according to the 
gross features exhibited, and arranged them in 
eight orders, as follows: 


I, Papule. V. Pustule. 
II. Squame. VI. Vesicule. 
III. Exanthemata. VII. Tubercula. 
IVeeBulle: VIIT.- Macule, 


But the insufficiency of this plan becomes manifest 
when it places in the same group diseases which not 
only have no relation to each other but which are 
widely dissimilar in appearance. Thus, scabies and 
variola appear together, because both exhibit pus- 
tules; varicella and eczema, because vesicles may 
be seen in both; acne and lupus, because tubercul- 
ous masses are developed in each, and so on. 

_ In 1845, Hebra published his attempt at a classi- 
fication of diseases of the skin on a basis of patho- 
logical anatomy, and his plan, simplified by himself 
and others, has since been followed more and more, 
until now a considerable portion of the dermatologi- 
cal world acknowledges it as the best basis upon 


- 
Fin 
*. 


CLASSIFICATION OF DISEASES.OP* THE SKIN: 2} 


which to arrange dermatological thought. The fol- 
lowing classification is based entirely upon this plan, 
although considerably simplified from that first pro- 
posed by Hebra, and that given in his text-book. 


CEA SOLE Le A PIONS Oe DiS PAS Bool eRe 
SKIN. 


Crass I. Morbi cutis parasitici. Parasitic Affections. 
ee Il. Morbi glandularum cutis. Glandular Affections. 
ee Ill. Neuroses. Neurotic Affections. 
oe IV. Exsudationes. Exudative or Inflammatory Affections. 
et V. Heemorrhagize. Hzmorrhagic Affections. 


ss VI. Hypertrophiz. Hypertrophic Affections. 
“VII. Atrophize. Atrophic Affections. 
“ VIII. Neoplasmata. New Formations. 


Class I. Morbi cutis parasitici. Parasitic Affections. 


x. Tinea trichophytina corporis (or tinea circinata). 


(or ringworm) capitis (or tinea tonsurans). 
( parasite — Tricho- barbze (or sycosis parasitica). 
(phyton tonsurans), cruris (or eczema marginatum). 


A. VEGETA- 
BLE, 2. Tinea favosa 


(or favus) ( parasite—A chorion Schenleiniz). 


. Tinea versicolor : a 
= (or pityriasis versicolor) (parasite—Microsporon fur fur). 


1. Phthiriasis core 2, Ste an 
sy pronet (or pediculosis) aie (parasite—Pediculus). 
2. Scabies (or itch) ( parastte—Acarus scabiet). 


Class II. Morbi glandularum cutis. Glandular Affections. 


I. Due to oleosa 
-faulty x1. Acne sebacea cerea (or seborrheea), 
secretion cornea 
Ie or. cathe 40) 
. DIsEASES excretion nigra (or comedo). 
OF THE of 2. Acne punctata , inte (or milium). 
SEBACEOUS | sebaceous 
GLANDS. matter. 3. Acne molluscum (or molluscum sebaceum). 


sebaceous glands with sur-~ 5. Acne indurata, 


II. Due to inflammation of the 4. Acne simplex (or vulgaris). 
rounding tissue. 6, Acne rosacea. 


22 


I. As to quantity of 
secretion. 
B. DIsEAsEsS 


OF THE II. As to quality of 
‘SWEAT- secretion. 
GLANDS. 


III. With retention of , 
secretion. 


Class III. Neuroses. 


. Pruritus. 
. Dermatalgia. 


. Anesthesia cutis. 


NK & iS) H 


. Hypereesthesia cutis. 


MANUAL OF DISEASES OF THE SKIN. 


Is Sart! vokee ama 
. Anidrosis. 


. Bromidrosis. 
. Chromidrosis. 


3 

4 

5. Dysidrosis. 
6. Sudamina. 


Neurotic Affections. 


. Zoster (herpes zoster or zona), 


. Dystrophia cutis (or trophic disturbances). 


Class IV. Exsudationes. Exudative or Inflammatory Affections, 


x. Rubeola (or measles). 
2. Rétheln (or German measles). 
3. Scarlatina. 
4. vetiele 
5. Varicella. 
A. eee Ry ANTE CS OR BN aceinia: 
: 7. Syphilis. 
8. Pustula maligna. 
g. Equinia (or glanders). 
to. Diphtheritis cutis. 
11. Erysipelas. 
x. Roseola. Smnlex 
I, Erythematous, 2. Erythema multiforme. 
3. Urticaria. nodosum. 
pos 
planus 
II. Papular. 4. Lichen ruber. 
scrofulosus. 
5. Prurigo. 
B. Or INTERNAL ; aes 
a ‘ape III. Vesicular. 6. Herpes progenitalis. 
Se gestationis. 
7. Hydroa. , 
: vulgaris. 
IV. Bullous. 8. Pemphigus ; foliaceus. 
9, Pompholix 
(or cheiro-pompholix). 
10. yee. (or folliculitis pilorum), 
11. Impetigo. 
V. Pustular. 12. Impetigo contagiosa. 
13. Ecthyma, 


. CLASSIFICATION OF DISEASES OF THE SKIN. 23 


VI. Multiform,7z.e¢., { 14. Eczema. ; 
erythematous, calorica. 


papular, ves- ve venenata. 
icular, pustu- tg. Dermatitis traumatica. 
lar, ete. medicamentosa. 


16. Dermatitis exfoliativa 
(or pityriasis rubra). 

17. Psoriasis. 

18. Pityriasis capitis. 


B. Or INTERNAL | VII. Squamous. | 
or Loca. 
ORIGIN. — 
Continued. ig. Furunculus (furunculosis). 
20. Anthrax (or carbuncle). 
: 21. Abscessus. 
22. Hordeolum. 


VIII. Phlegmonous, 


i 23. Onychia. ‘ 
IX. Ulcerative. 24. Ulcus ; simplex. 


venereum, 


Class V. Hzemorrhagize. Hzmorrhagic Affections. 


simplex. 

xz. Purpura ~ rheumatica (or peliosis rheumatica). 
hzemorrhagica. 

2. Hzematidrosis (or bloody sweat). 

3. Scorbutus. 


Class VI. Hypertrophize. Hypertrophic Affections. 


1. Lentigo. 

A. OF ies 2. Chloasma. 4. Morbus Addisonii. 

\ 3. Melanoderma. 5. Nzevus pigmentosus. 
1. Ichthyosis. 

B, Or Epriper- 2. Keratosis pilaris (or lichen pilaris). vulgaris. 
MIS AND 3. Cornu cutaneum. 6. Verruca J Senulis: 
PapPiLtta. | 4. Clavus. : necrogenica, 

5. LTylosis (or callositas). acuminata. 
1. Scleroderma. 4. Elephantiasis (Arabum). 
C. SS Ae aie 2. Morphoea. 5. Dermatolysis. 
* ( 3. Sclerema neonatorum. 6. Frambeesia (or yaws). 
D. Or Harr. x. Hirsuties. 2. Nzevus pilosus. 
E. OF Nait. r. Onychogryphosis. 2. Onychauxis, 


Class VII. Atrophise. Atrophic Affections. 
x zt. Albinismus. 2. Leucoderma (or vitiligo), 
A. Or PIGMENT. ; 3. Canities. 


ropria. 
x. Atrophia cutis oe (or strize atrophicz). 
‘ B. Or Cortum. maculosa (or maculz atrophicze). 


2, Atrophia senilis. 


24 MANUAL OF DISEASES OF THE SKIN. 


1. Alopecia. | 2. Alopecia areata. 
C. Or Hair. 3. Trichorexis nodosa. 4. Fragilitas crinium (or atrophia 
pilorum propria). 


D. OF Nait. Onychatrophia. 


Class VIII. Neoplasmata. New Formations. 
I. Benign New FormatIons. 


A. Or ConnEcTIvE {1. Keloid. 2. Fibroma (or molluscum fibrosum), 
TISSUE. 3. Xanthoma (xanthelasma or vitiligoidea). 


B. Or Fatty TissuE. Lipoma. 


C. Or GRANULA- eT aie erythematosus. 2. Scrofuloderma, 
TION TissuE. ) ** “UP vulgaris. 3. Rhinoscleroma. 
,D. Or BLoop 1. Nzevus vasculosus. _ 
VESSELS, | 2. Telangiectasis (or angioma). 
E. Or Lympuatics. Lymphangioma cutis. 
F. Or Nerves. Neuroma cutis. 
II. Maricnant NEw ForMATIONS. 
maculosa Alt 
xr. Lepra tuberculosa > (or elephantiasis Grzecorum). 
anzesthetica 
2. Carcinoma. 
3. Epithelioma. ; 
idiopathicum. 


4. Sarcoma ; pigmentosum (or melanosis). 


CLEA TE ahve 


RELATIVE FREQUENCY OF DISEASES OF THE SKIN: 
STATISTICS OF EIGHT THOUSAND CASES. 


THE relative frequency and importance of the 
different diseases of the skin may be in a measure 
judged from statistics, although they often fail to rep- 
resent the true frequency of the affections recorded. 
Thus, very few of the febrile diseases of the skin ap- 
pear here, such as measles, scarlatina, and small-pox, 
because they comparatively seldom fail under the 
observation and care of the specialist; and many of 
the more trivial skin disorders occur also in much 
fewer numbers than in reality, as such cases rarely 
apply for treatment. Again, certain of the most 
common diseases, eczema and acne, are not as 
largely represented as they might be, inasmuch as 
many cases of eczema are left untreated, and acne 
is very generally disregarded. 

The statistics here presented are from eight 
thousand cases observed by the writer in private 
practice, and in the Demilt Dispensary and the 
Out-patient Departments of the New York and 
Bellevue Hospitals. It was thought best to exclude 
a large number seen in other institutions, as records 

2 25 


26 


MANUAL OF DISEASES OF THE SKIN. 


of them had not been kept with sufficient uniform- 


ity and accuracy. 


ANALYSIS OF 8,000 SKIN CASES. 





Private Practice. 


DISEASE. 


Acne 


eee ec ee eeost ee ee se eeos 


ZEAL > Opa Bat air a ae ee 4 
Atrophia cutisne es So 
Bromidrosis 
Cacatrophia cutis........ 
Canities 


eeceeeo ee eee eaeeeen 


ere eoeve sce ee eeee 





Clavus 
Congestio folliculorum 
Cormtt ‘cutaneiin... 2... «7: 
Dermatalgia 
MIETOVACITIS; Cire ct ee cake 


Elephantiasis Arabum....|.... 
BETO ELE ys, (ale starsat s vite oe 

Epithelioma 
EDEVSIDOLAG sae mies ue ch ae 
HLA Neca «fen oc 
Excoriationes 
Folliculitis capitis 
Furunculus 


eeereeeoe eee ee 


eee eeeneees 
9. 478 ‘oe 6 
eee eee rere e eve 


Herpes.isi5 ae ea 
Py lirOa, cru is nie <i the xc sie 5 I 6 














Public Practice. 








a I I 
-: 3 3 
I 2 3 
eel ae aEO} SLO 
) 4 7 
ee I I 
Theeis « i 
69] 73) 142 
I 3 4 
10) | a Sy | 
873] 928)1,801 
nals 2 2 
DAL Pal 7) fee 
31} 54) 85 
27 OI 88 
2 I 3 
see ye I 
58} 65) 123 
see I 
56) 55] III 
2 I 3 
2 ‘ 2 














Le 
sr + 
SON NANT NOOULD HOO 


NN 

O 
Oo oO STH 
SH ONWWO CO 


FREQUENCY OF. DISEASES OF THE SKIN. 


ANALYSIS OF 8,000 SKIN CASES.—Continued. 


27 





Private Practice. 


DISEASE. : J Be 

$23 

a fe |e 
PA VOETWATOSIS ss 5 dale +6000 «6 5 3 8 
Eiypertrichosis.........<; Tie 23) ey 
MCR URVOSIS: 59.50 -te s «5 3 e/as <b 10 5| 15 
AAUP CLIT Osho: pee ses Rie Merete ede tas ears 
Impetigo contagiosa...... 2 5 7 
Impetigo herpetiformis...| .... 2 2 
POCO Beta Se ced ois Pees chet 3 4 5, 
BentipGe onto. a's <3 ns I 2a 
Ne Oe gic Lae eh ate bio Ai ies 6% 4 
PCUCOGETMA, <4. sath n s0rek6 9 Si T7 
PROGR eves 5 doe cers cierespre bai 29} %I5| 44 
MEALS Aes logerectaels <p as en» Pie ety es? 
Lymphadenoma......... I I 
Lymphangioma......... beg x 
Macula pigmentosa ...... Valter ae 
DE ariaaa cele a edie sae Seed eae ee 
BROT eam tee eos 9d «once ee I 3 4 
POTD Ceo: ects oo eas 0 ose I 4 5 
PA ils taii. aay winteha oq ttacs 4) *12)- 16 
BNCULOMIA se o.. bonis dia ese sis ; Sei eas 
@Onychatrophia Me hs osu AS sie silts 
Cry CNA LS ie ain shee ol S95 2 4 6 
PALOMA rs steree sn b.4 9a. 4 ake ee 2 
Papulo-vesicular eruption.) ....) 2 .| 7+... 
ParouyCMiasca... «o1ak ss 22 pana hae ohep atuie 4 
PUM OUS. fh. carats. 8:0) oda 3 | Io 
LEON ON | nfs wh vate vate e's a eMARR Nid <tehs tices eters 
PAE IRIASIS heli nal osha 25, vit 3 Si 2 TT 
BOLUYTIASIS! 30 WE bo aloe w vies CY age A co a 
POT DUCIIX. fag 2% vin so d's «s Ale vcsists 4 
LOT O 1. isa Ae 2 SR a ee I I 
PUTAS ay ts cae a wee we 22-airg = a0 
PsOviasisy ead so an cc cas oe 2% Pe BARS TST 
eg e URe erae eeeies 9 Py Oe 8 
Rhinoscleroma... ...... ofa as I I 
































Public Practice. 








acy oie 
or: 
P= 7 H 
II 8| 19 
tt; : ‘4 Re 
5 8 13 
Tie L2G 
Alport 4 
SEN Pld he 
2 I 3 
43| 61] 104 
J) hOCe ee OF 
S. Sai a9 
1 alte 2 
Z ee I 
ns I I 
I 2 3 
| 7} 10 
Dit farce 2 
Ph ies, ae 2 
6 5 It 
PD i 2 
1 et a T 
: 4 5 
2 5 7 
Whey nets I 
155} 231] 386 
Alp 14/538 
55, 57) Ite 
Q2| . 110} 202 











Ny 
HNIMAOST ND YN OOM HN ND A 


La 


Leal 


28 MANUAL OF DISEASES OF THE SKIN, 


ANALYSIS OF 8,000 SKIN CASES.—Continued. 






































Private Practice. Public Practice. 
OH 
DISEASE. 3g . : J Se as 
Lv a v 3 od a0 
S818, | S458 eee 
Fy a 
EPOSCONA sas eels Com ae Pte Ws ce t 5 6 6 
BLOUGLi ays crs susneefas Gistm tes Q 8 TEM aA Cg Mee | I2 
RTOCS Was alels, bg ws = al sisi oie ai: I 1 UAE re seg | yeas I 
DATCOMA We eg hs 2 evi ee FAP oat 3 Tl ere I 
SCALES: a ooo the seal seh weird ee 9 tl cio 66} 52) rr8i| 128 
Ra CAarlattiay. Gelccs ne eae ee Nate I Ei se se ek, are) Bees I 
SCLEPGderiMm a, 4 tte ele = I 2 3 I I 4 
Scrotulodermacss cy. sen i 2 3 E4|i £223)4 -.27 30 
mtrophulus pruncinosnss.| Bes at «sem iol wallet a i I zh 
PYVCOSIS “Sse ets eels sate ete This ZoLs Ttee se oe 12 27 
SSD ILIG: f Oitia's 5 ele si actnte 92} 61] 153]| 344) 302] 646)| 799 
SYPAlOPHOpidw .tsss. se > aks BS oe I I I 
Welaneiectasis.i.is sm sve'as © $003 I db Na z ci 2 
PING R Wt nels wee aie orale se 87} / 1137] 224i) elAZi— 404) 22304 15360 
Trichorexis nodosa : Aik a. Al Mae lie ote ol Me eat 4 
MURIEL OT ae lets sie cgunsye State 6 =i 2 3 3 
BIVIOSIS: seco ale 42 acre a aeht Pare ec ht fa eee hin east I I I 
ESTs. 115s eles witiate el setete 8 6} 14 88} 79} 167}| 181 
(OS qele tet Mem ees: ee oY 14) =30) 444 62} 93} 155\| 199 
WV ACCINID. ccm Ne ateuien «aires MS a Sst eh 7) een 2 2 
WariCella ck sche oe 5 wale ko 3 3 6 9 Di rs 21 
Varicella prurigo -... .. nee eae Sra tenes Disa ae 2 2 
MATIO A ste oaks tire Se ek ae 4 I Bil ete ed aie elemee ane 5 
Warioloid gach wee oes see pop el ke af Eek I I 
PEITUICA Von cess Sete sale 5 Oh TAlid $30) > rT ey 55 
PRANCHOMA TW s w dere ote oreie 25 4 6 I 3 4 Io 
AETOCCTINA aici ainss saris 4 2 6 2 2 4 10 
Doubtful diagnosis....... 2 I 3 4 4 8 II 
I, 320/1,263)2,583 |2,577|2,840)5,417 |8,000 











Eczema is seen to come first in point of frequency, »~ 
it occurring in 2,679 of the 8,000 cases, or 33.48 per 


FREQUENCY OF DISEASES OF THE SKIN. 29 


cent. of the whole; the real frequency is probably 
even more than one-third of all skin affections as 
presented to the general practitioner, since the many 
cases of infantile eczema of family practice do not 
find their way into the statistics of the specialist ; 
certainly far more than one half of the eruptions in 
small children (excluding eruptive fevers) are eczema. 

Acne is the next common disease here presented, 
with 973 cases, or 12.16 per cent. ; here again statis- 
tics fail to give the correct proportion, owing to the 
feneral neglect of this eruption. Acne formed more 
than one-fifth of the private cases. 

Syphilis comes next in frequency, forming about 
ten per cent. of all the cases, the proportion being 
somewhat larger in public than in private practice. 

The next name on the list, as to point of numbers, 

is phthiriasis, giving 397 cases, or nearly five per 
cent. in which the lesions were caused by lice; there 
were only eleven among the 2,500 private cases, 
showing how seldom the condition occurs among 
the upper classes. 
_ The eruptions due to vegetable parasites appear 
next in frequency, in almost the same proportion in 
private and public practice, namely, forming four 
and a half per cent. of all cases; of these, two-thirds 
were caused by the parasite trichophyton tonsurans, 
giving rise to the various forms of ringworm, while 
there were only thirty-one cases of favus in the 
entire 8,000. 


30 MANUAL OF DISEASES OF THE SKIN. 


Psoriasis appears next, and sixth on the list, with 
333 cases, or a percentage of but 4.16, showing it to 
be much less common than is usually supposed ; 
the proportion of cases in private and public prac- 
tice was about the same. 

Urticaria is probably much more common than 
these statistics indicate, inasmuch as many patients 
with other diseases will give a history of being sub- 
ject to this eruption, for which they will seldom 
seek relief; it formed but 2.49 per cent. of all cases. 

The remainder, even of the more commonly 
known eruptions, appeared in still smaller propor- 
tions, under two per cent., and a number of cutane- 
ous maladies occurred but once or twice among the 
entire number of cases analyzed. 

Zoster or shingles formed but a trifle over one per 
cent. of the 8,000 cases, although the eruption is so 
startling and often so painful that those affected 
generally apply for relief. Scabies was very rarely 
seen, but 118 times in public and ten times in private 
practice; lupus formed but 0.86 per cent.; purpura 
but 0.49 per-cent.; ichthyosis, 0.35 per cent.; nzevus, 
0.33 per cent.; leucoderma, 0.25 per cent.; pemphi- 
gus, 0.21 per cent.; keloid, 0.14 per cent. ; morphcea, 
0.10 per cent.; and scleroderma but 0.05 per cent. 

In regard to sex the patients were remarkably 
evenly divided, 3,897 males to 4,103 females in the 
total numbers; but in individual diseases great dif- 
ferences will be found. Thus in acne the females 


FREQUENCY OF DISEASES OF THE SKIN. 3 


are double the number of the males, while with 
alopecia there were twice as many males as females. 
Chloasma is seen to be almost exclusively an affec- 
tion belonging to females, there being forty cases to 
two of males, while sycosis belongs to the male sex. 
In eczema the sexes are pretty evenly divided, 1,402 
males to 1,277 females; with lupus the females were 
almost three times as many as the males. Psoriasis 
presented almost an exactly equal number of both 
sexes, 169 males, 164 females. 


CHAPTER V. 
DIAGNOSIS. 


THE diagnosis of individual diseases of the skin 
will be treated of in connection with each affection, 
but a few general rules or considerations may be 
here noted. Diseases and lesions of the skin should 
always receive very careful inspection and study, 
for, however simple the case may appear at first 
sight or in any of its elements, it is quite possible 
for other portions of the eruption to exhibit quite 
different features;.and unless disease is taken asa 
whole, and also unless it is understood in each and 
-all of its parts, no perfectly correct diagnosis will be 
arrived at, and consequently no intelligent thera- 
peusis. 

The first consideration, therefore, has to do with 
the examination of the patient. This should always 
be made in a very general and complete manner; 
the practitioner should never be satisfied with in- 
specting only a portion of the eruption present, but 
must insist upon viewing the whole of the diseased 
surface, and it is also important to examine the 
neighboring healthy skin as well. It is, likewise, 

32 


DIAGNOSIS. 23 


very necessary to observe and note carefully the 
distribution “of the eruption, for, as will be developed 
elsewhere, different affections have different seats 
of predilection, and modes of development and ar- 
rangement of their elements, which will often aid 
very considerably in the study of the case. As in- 
stances may be mentioned the proneness of eczema to 
affect the flexor surfaces ; while psoriasis, ichthyosis, 
and lichen are found by preference upon the ex- 
tensor surfaces of the body. In studying the dis- 
tribution of the eruption it is also well to bear in 
mind the tendency which certain eruptions have for 
a particular form of distribution; thus, the inclina- 
tion to circular arrangement of the lesions of syphilis, 
the disposition of the vesicles of zoster along the 
lines of nerve tracts, and the peculiar grouping of 
the vesicles of herpes febrilis and preputialis, are all 
very striking, while the rather symmetrical develop- 
ment of tinea versicolor, and the circular form and 
irregular location of patches of ringworm are like- 
wise characteristic. 

It is important always to discover the primary 
lesions of an eruption, the form in which it makes 
its first appearance; for, although when well devel- 
oped it may or may not have characters which are 
distinct, the earlier phases of its evolution will very” 
generally point towards the proper diagnosis. The 
primary elements are generally discoverable near or 


outside the main line of eruption, if at all, although 
2% 


34 MANUAL OF DISEASES OF THE SKIN. 


occasionally they will reappear very characteristically 
in portions already traversed by the disease. Some- 
times the earliest stages are not present at the time, 
all of the lesions having passed into a more fully 
developed or retrograde state; but the previous 
condition may then be generally learned by very 
accurate questioning. 

In making the diagnosis of an eruption, there are 
two methods by which the end can be arrived at; 
these should be employed together, in order to at- 
tain any true accuracy. The first is by recognizing 
the actual characters or features of disease present, 
and their likeness to a well known lesion or malady 
of the skin; the second is by exclusion, namely, by 
considering other eruptions which the one present 
might be mistaken for, and excluding each in turn, 
by the absence of some particular, distinctive fea- 
ture belonging to it. As remarked before, both 
methods must be employed where the case is at all 
doubtful; indeed, until one is familiar with the sub- 
ject, this process of mental logic should be asso- 
ciated with every case. 

There is nothing really so very special or peculiar 
in the lesions which are found upon the skin, or in 
the diagnosis of the diseases which affect the integu- 
ment. The pathological processes which occur here 
are precisely the same as those which take place in 
other portions of the body ; congestion, inflamma- 
tion, the results of altered nutrition, as hypertrophy 


DIAGNOSTS. 35. 


and atrophy, together with the development in the 
tissues of new formations, as cancer, etc., constitute, 
with the alterations caused by parasites, the lesions 
which are found upon the skin. The variety of the 
changes produced by these processes, results in con- 
siderable confusion to one unaccustomed to look 
upon them ; but a little careful observation will soon 
distinguish the elements of disease belonging to the 
various eruptions and processes, and by thus analyz- 
ing and separating the lesions found upon the skin 
a diagnosis can generally be made with certainty. 
True it is, that the gross features and grouping of 
elements seen in some skin diseases enable the prac- 
ticed eye to make a probable diagnosis in many 
instances at first sight; but as successful treatment 
depends absolutely upon accuracy of diagnosis, the 
greatest care should be exercised in determining this 
exactly. 

Various agencies effect certain pathological 
changes in the skin structure, which have received 
the name of /eszons,; each of these exhibits to the 
eye, and often to the touch, features which are dis- 
tinctive, and which, if recognized, establish with 
more or less of certainty the nature of the disease 
process present. It is essential, therefore, to fix 
firmly in the mind the elemental lesions, and to 
connect them with the various diseases with which 
they are associated. 

We will first give a few brief definitions of the 


36 MANUAL OF DISEASES OF THE SKIN. 


terms used to express the parts or elements of 
which eruptions are composed; these are spoken 
of as primary lesions, and secondary lesions, the first 
the direct results of disease, the second, a more or less 
consequent condition. 

Of each of these there are eight, as follows: 


PRIMARY LESIONS. SECONDARY LESIONS, 


. Tinctura ; stain. 
. Squama ; scale. 


. Macula; spot, macule. I. 
. Papula; papule. 2 

Vesicula ; vesicle. 3. Crusta; crust. 

. Bulla; bleb. 4. Infiltratio; infiltration. 
. Pustula; pustule. 5. Fissura; fissure. 
. Pomphus ; wheal. 6. Excoriatio ; excoriation. 
. Tuberculum ; tubercle. y Bie lie cccmpe il Glee 
. Phyma; tumor. 8. Cicatrix; scar. 


Ont anP WwW DY H 


First, of the premary lesions of the skin, eight in 
number. 

1. Macula. Spots or macules are of various 
sizes, colors, or shapes; not elevated or depressed. 
These may be congestive, hemorrhagic, pigmentary, 
or from extraneous causes. | 

Congestive maculz are seen in dermatitis, eczema 
erythematosum, erysipelas, erythema, leprosy, nevus 
vasculosus, roseola, rotheln, rubeola, scarlatina and 
syphilis: hemorrhagic macule. occur in purpura, 
scorbutus, and insect bites: pigmentary macule are 
found in Addzson’s disease, chloasma, ephelis, leuco- 
derma, melanoderma, morphea, nevus pigmentosus, 
scleroderma, syphilis, and xanthoma: macule from 


DIAGNOSTS. 37 


extraneous cause are seen in nitrate of silver stain- 
img, and from parasites in ¢znea trichophytina and 
tinea versicolor. 

2. Papula. Papules or pimples are small solid ele- 
vations of the skin, inflammatory or neoplastic. 

Inflammatory papules occur in acne, dermatitis, 
eczema papulatum, lichen, phthiriasis, prurigo, pur- 
pura, scabies, syphilis, urticaria papulosa, and variola : 
neoplastic papules are seen in keratosis pilaris. 

3. Vesicula. Vesicles, or small water blisters, con- 
sist of small elevations of the epidermis, with clear 
fluid contents. 

Vesicles appear in dermatitis, dysidrosts, eczema, 
herpes, scabtes, sudamina, varicella, variola, and zoster. 

4. Bulla. Blebs, or larger water blisters, are so 
called from their resemblance to bubbles on the sur- 
face of agitated water. Blebs may be of any size 
from that of a split pea upward. 

Bulle are observed in kydroa, leprosy, pemphigus, 
pompholix, scabies, and syphilts infantile. 

5. Pustula. Pustules represent small, round ele- 
vations of the epidermis, containing pus. 

Pustules are seen in acne, dermatitis, eczema, 
ecthyma, equinia, furunculus, tmpetigo, impetigo con- 
tagiosa, phthiriasis, pustula maligna, scabies, sycosts, 
and varzola. 

6. Pomphus; a wheal. The flat, solid, slightly 
elevated lesions of urticaria or nettle rash are called 
wheals, or pomphi. 


38 MANUAL OF DISEASES OF THE SKIN. 


In addition to urticarza, wheals may also appear 
about the dz¢es of insects. 

7. Tuberculum ; atubercle. This term, which has 
no relation to tubercles of the lungs, refers to small 
solid elevations of the skin, larger than papules. 

Tubercles occur in acne, carcinoma, clavus, epithe- 
lioma, fibroma, lepra, lupus, lymphangioma, rhinoscle- 
roma, sarcoma, scrofuloderma, syphilis, and verruca. 

8. Phyma,; a tumor. This is a large swelling in 
or upon the skin, and may be of any size above that 
of atubercle. Generally masses larger than a cherry 
are spoken of as tumors. 

The following diseases may present lesions classed 
as tumors: carcinoma, dermatolysts, elephanttasts, 
fibroma, keloid, lepra, lipoma, rhinoscleroma, sarcoma, 
and syphilis. 

The secondary lesions of the skin, eight in number, 
are as follows: 

1. Zinctura ;astain. A discoloration of the skin 
more or less permanent, left after a preceding le- 
sion. 

Stains may remain for a varying period after all 
inflammatory affections; they are most commonly 
seen after acne indurata, ecthyma, furunculus, lupus, 
phthiriasis, psoriasis, and purpura, and after certain 
lesions of syphzlzs, and ulcus they are apt to be per- 
manent. 

2, Squama,;ascale. A portion of the epidermis 
more or less diseased and detached. 


DIAGNOSIS. 30 


Scales occur in dermatitis exfolrativa, eczema, 
achthyosts, lupus, pemphigus foliaceus, pityriasis, 
psoriasis, rubeola, scarlatina, syphilis, tinea favosa, 
tinea trichophytina, and tinea versicolor. 

3. Crusta,; a crust. A dried mass, generally of 
pus and epidermis, the product of some disease of 
the skin. 

Crusts follow inflammatory and destructive le- 
sions; they are principally seen in dermatztts, eczema, 
ecthyma, favus, furunculus, herpes, hydroa, tmpetigo, 
lepra, lupus, pemphigus, phthiriasis, screfuloderma, 
sycosts, syphilis, vaccinta, vartola, and zoster. 

4. LInfiltratio ; infiltration ; a thickening and hard- 
ening of the skin from disease. In this the normal 
suppleness and elasticity are lost, and the skin 
readily breaks with each movement of the part. 

Infiltration and hardening of integument is seen 
in eczema, epithelioma, lepra, morphea, rhinoscleroma, 
scleroderma, and ulcus. 

5. Pussuva; a fissure, or: ckack in the’ skin, con- 
sequent upon previous infiltration. 

Fissures appear principally in connection with the 
infiltration occurring in eczema, lepra, psortasts, and 
syphilis. 

6. Excoriatio ; excoriation and ulceration of the 
surface, generally caused by scratching. 

Excoriations or scratch marks are observed in 
connection with eczema, phthirtasis, prurigo, scabtes, 
and urticaria , also in consequence of dztes of insects. 


40 MANUAL OF DISEASES OF THE SKIN. 


7. Ulcus; an ulcer. An excavation in the skin 
made by disease. Ulcers generally extend deep into 
the true skin, and leave a scar. 

Ulcers may occur in anthrax, carcinoma, chancrotd, 
dermatitis, eczema, ecthyma,. epithelioma, equintia, 
furuncle, herpes preputialis, lepra, lupus, onychia, 
pustula maligna, sarcoma, scleroderma, scrofuloderma, 
syphilis, and from traumatic causes and varicose 
veuns. 

8. Cicatrix ; a scar. A new growth made up of 
hard, fibrous tissue, which replaces that lost by dis- 
ease or injury. 

Scars may follow ulcerative lesions in the diseases 
just mentioned, and are also seen in acne, atrophia 
cutis, favus, sycosts, vaccinia, varicella, vartola, and 
Zoster. 


All the lesions occurring on the skin, will be found 
to be made up of these elements, sometimes of a sin- 
gle one alone, far more often of several combined. 
Especially do we continually find those belonging 
to the two classes intermingled, namely, primary 
lesions combined with their results, or secondary 
lesions of the skin, and the one may be quite as 
characteristic of the disease as the other. Thus, 
the pearly, imbricated scales of psoriasis, and the 
yellowish greasy scales of seborrhoea are both suffi- 
ciently pathognomonic. The crusts of impetiginous 
eczema and of syphilis, the scars of certain diseases, 


DIAGNOSIS. Al 


and the infiltration of eczema, all point clearly to 
the affections to which they belong. In certain af- 
fections we see little except the secondary lesions, 
as in phthiriasis, where the scratch marks or excori- 
ations are almost pathognomonic; and in favus the 
entire external lesion is made up of crusts and 
scales. It will be observed that many diseases ap- 
pear under several of these lesions, according to the 
variety or stage of the eruption. 


To observe diseasés of the skin satisfactorily, it is 
necessary that there should be good light; for this 
purpose daylight is almost essential, and plenty of 
it, preferably from a northern exposure. It is almost 
impossible to judge correctly of the color and char- 
acter of skin lesions by artificial light. 


CHAPTER VI: 
ETIOLOGY. 


THE etiology of various diseases of the skin has 
always been a matter of considerable difference of 
opinion among writers, but the subject is being 
cleared up more and more underithe light of modern 
science and accurate study, and many points are now 
placed beyond the reach of controversy. In former 
periods it was supposed that all cutaneous disorders 
were manifestations of an internal poison or evil, a 
materies morbt, seeking exit by this channel: hence 
the general name given to this class of affections 
was eruptions (from the Latin e-rumpo, I burst 
forth), as is also signified in the Greek term, eczema 
(from &€xGé@, I boil over). This idea has by no 
means entirely disappeared, either from the public 
or professional mind ; in few, if any instances, how- 
ever, is it correct. 

Modern study has demonstrated a certain group 
or number of diseases of the skin to be entirely due 
to the local effect upon the integument, or its ap- 
pendages, of vegetable parasites which find a habitat 
there; certain other lesions on the skin are wholly 
due to other local irritants, as the burrowing of the 

42 


LITOLOGY. 43 


scabies insect, or the scratching practiced for the 
relief of pediculi, or from other causes. Still other 
conditions recognized as disease are the direct re- 
sults of heat and cold, or mechanical and chemical 
irritants, as injury, dye stuffs, poison ivy, etc.; 
another group of affections are known to be purely 
local alterations in the skin tissue, such as fibroma, 
epithelioma, keloid, and the like. Yet other diseases 
have most intimate internal relations, such as acne, 
eczema, and urticaria; others, finally, as syphilis 
and the exanthemata, are the result of specific poi- 
sons. 

It will be impossible, therefore, to enter here fully 
into the subject of the causation of diseases of the 
skin, but the matter will be briefly referred to in 
connection with each malady. A few general con- 
siderations, however, may be of value. 

While some diseases are definitely due to a local 
cause, as a parasite, and others to'a specific poison, 
in regard to a large number the etiology is by no 
means fixed, and both internal and external causes, 
as also individual and family tendencies, are of im- 
portance in their production. These may be briefly 
alluded to. 

1. Internal Causes.—Food, which is wrong either 
in quantity or quality, is a frequent cause of skin 
disorder, as will be dwelt upon in the chapter on diet 
and hygiene. Derangements of the internal organs, 
as indicated by dyspepsia, constipation, and urin- 


A4 MANUAL OF DISEASES OF THE SKIN. 


ary disturbance, likewise sexual disorders and ner- 
vous derangements, are frequently very closely con- 
nected with skin lesions; and the permanent cure of 
the latter often depends upon the successful relief 
of the former. Debility isalsoan important element 
to consider in this connection; and infancy, denti- 
tion, puberty, pregnancy, and the menopaus have 
all relations to cutaneous maladies. The internal 
administration of some medicines, as quinine, iodide 
and bromide of potassium, and copaiba, and other 
drugs, is sometimes followed by eruptions of peculiar 
nature. 

2. External Causes.—Parasites, animal and vege- 
table, heat and cold, chemical and vegetable poisons, 
and mechanical irritation, as by friction, harsh un- 
derclothing, and above all by scratching, are fruitful 
causes of skin lesions, and must all be looked for. 
In some instances they are the sole efficient cause, 
and the eruption fades away when they are re- 
moved ; in other cases they are but a single factor, 
and the real cause is found in the internal or indi- 
vidual state. Thus, local agents may excite an 
eczema in one predisposed thereto; but the same 
irritation practiced upon a dozen other individuals 
will excite but a temporary inflammation of the skin. 
The lesions of late syphilis are frequently deter- 
mined as to their seat by a local injury. 

3. [Individual and Family Tendenctes—Some indi- 
viduals are far more prone to have skin affections 


ETIOLOGY. 45 


than others, even as the lungs or kidneys are more 
often affected in one person than in another; those 
with light complexion and hair are more inclined to 
skin diseases than the dark. Again, families present 
the same peculiarity ; some affections are hereditary 
to a greater or less extent, such as syphilis, leprosy, 
cancer, and psoriasis ; eczema sometimes appears 
to be inherited, but.in reality this is rarely the case. 
The gouty, strumous, and nervous habits or states, 
whether hereditary or acquired, are of importance 
in connection with this subject. 

Other elements to be taken into consideration as 
bearing upon etiology, are the seasons, climate, oc- 
cupation, age, and sex, as will be developed in later 


pages. 


GOAT AGRI an. 


CLASS I. MORBI CUTIS PARASITICI.—PARASITIC 
AFFECTIONS. 


THE first class of diseases.in our classification em- 
braces eruptions having a well recognized and easily 
defined cause: namely, the existence in or upon the 
skin of parasites, whose presence and irritation cause 
the phenomena of disease. These parasites are rec- 
ognized to be of two kinds—vegetable and animal. 
The first group embraces three distinct kinds or va- 
rieties of disease; the second, two. 

The vegetable parasites producing the three dis- 
eases are supposed to be distinct one from another ; 
they have not been found to be interchangeable in 
causing disease. The three vegetable parasites are 
the ¢rzchophyton tonsurans, causing the varieties of 
tinea trichophytina or ringworm, the achorion Schin- 
leinit, causing tinea favosa or favus, and the micro- 
sporon furfur, inducing tinea or pityriasis versicolor. 
-The action of these parasites is a purely local one ; 
_ that is, the lesions are produced by the local action 
of the vegetable growth upon and in the elements 
of the skin, and not by absorption or by any action 


of the parasite upon the blood or the system at large. 
46 


PARA SLLIC AFFECTION S. 47 


When the eruption is communicated to another per- 
son, or develops elsewhere on the same individual, 
it is always by direct or indirect transference of the 
germs of the parasite to and upon the affected spot. 

1. Tinea trichophytina. Synonym: Azugworm. 
The growth of the parasite trichophyton produces 
quite different appearances as it affects the different 
portions of the body, and four distinct varieties of 
eruption fromit are recognized: Namely, ¢zxca trz- 
chophyton corporis, — capitis, — barbe, and —cruris, 
affecting respectively the general surface and extrem- 
ities, the scalp, the bearded face, and the genital 
region. Although they are really the same disease, 
they will best be described and treated of separately, 
so different are the appearances at times presented. 

TINEA TRICHOPHYTINA CORPORIS.—Synonyms: 
Ringworm of the body, Tinea circinata; Herpes ctrcina- 
tus. This includes the eruption due to this parasite 
upon all parts other than the hairy scalp, the bearded 
face, and the genital region; it is very commonly 
seen upon the face and hands of children. It is 
characterized by the development of a small red 
spot which enlarges peripherally with considerable 
rapidity, so that in two or three days or a week it 
may attain the size of a circle half an inch or more 
in diameter; as it increases at the border, it has a 
tendency to clear in the center. The margin is 
sharply defined, slightly raised, of a well marked 


A8 MANUAL OF DISEASES OF THE SKIN. 


red, and covered with a small amount of easily re- 
moved scales. Sometimes, in delicate skins, a few 
minute vesicles will form on a large spreading bor- 
der (herpes circinatus) ; this, however, is rare. When 
at all well developed, the center of the patch is of a 
dirty yellowish color with more or less scaling. 
There may be one or several patches; I have counted 
as many as one hundred and three on one child; 
they may attain some size, and by coalescing may 
form larger patches, or, the center clearing, gyrate. 
forms may be produced by the red margins. They 
generally give rise to but little physical discomfort 
other than a slight itching. 

Diagnosis. ‘Tinea circinata is most likely to be 
confounded with psoriasis, squamous eczema, sypht- 
lis, and erythematous lupus. The history of the case, 
and the rapid development of the circles of ringworm, 
with a tendency to clear in the center, will differ- 
entiate them. The diagnosis is established with cer- 
tainty in all the forms of ringworm by the discovery 
in the scales and hairs, of the parasite trichophyton © 
tonsurans. The examination is best made by scrap- 
ing the surface with a dull knife and placing the 
débris in a little liquor potasse and glycerine, upon 
the slide of a microscope, and examining it witha 
power of from two to three hundred diameters. The 
mycelium appears as minute, slightly greenish tubes 
with parallel sides and rounded extremities, often 
branching, and the spores as minute rounded bodies, 


PARASITIC AFFECTIONS. 49 


of even size, refracting the light strongly: some 
little care is necessary to distinguish the latter from 
fatty globules. 

TINEA TRICHOPHYTINA CAPITIS. Synonyms: Azzg- 
worm of the scalp; Tsnea tonsurans , Herpes tonsurans ,; 
Trichophytosts. Ringworm of the scalp is not always 
as easy of recognition as might be supposed, and in 
cases which have lasted any length of timethe diag- 
nosis may be very difficult. The eruption begins, 
as upon the face and body, with a small red point, 
which increases peripherally in amore or less circular 
form, until it has attained almost any size. When 
first presented there are commonly seen one or more 
patches with a diameter of from half an inch upwards, 
upon which the hairs are broken and stubbed, and 
the surface covered with a dirty grayish scaling; 
the history will be given that these were noticed 
quite recently, and mainly by the loss of hair. 
Sometimes instead of these dried patches there is 
an inflamed condition, and each point of attack of 
the parasite will be marked by a small pustule or 
mass of inflammation, surmounted by a crust; but 
generally other non-inflamed patches will also be 
visible. 

Sometimes the tendency to inflammation will be 
so great, that in place of single small points, the 
entire patch, half an inch or more in diameter, will 
become inflamed, boggy, slightly elevated above 
the skin, and tender upon pressure. When the dis- 


Bs, 


50 MANUAL OF DISEASES OF THE SKIN. 


ease has lasted a length of time, each hair is seen 
to stand in a little well of pus, from which it can be 
extracted without pain; and a gummy, purulent 
fluid exudes from the hair follicles on moderate 
pressure. This form orcondition of the disease has 
received the name of ¢znea kerion. 

On attempting to extract the hairs from a non-in- 
flamed patch of ringworm, the stump readily crum- 
bles in the forceps without drawing the root with it; 
if the patch is scraped with a dull knife, many broken 
bits of hair will be found with the scales, which are - 
seen to be filled with the spores of the parasite. 
This broken condition of the hair which is seen on 
these patches, may be readily discovered by passing 
the finger lightly over the surface at a slight dis- 
tance from the scalp. 

In certain old cases the distinctive features of ring- 
worm may be lost, and the scalp is moderately scaly, 
with thin hair, and among the long hairs may be 
found many which are broken and stubbed, as in the 
patches previously described. 

Diagnosis —Ringworm of the scalp may be mis- 
taken for eczema, psoriasis, seborrhea, and perhaps 
syphilis. The stubbed and broken condition of the 
hairs, and the presence of the parasite, are sufficient 
for the diagnosis. 

TINEA TRICHOPHYTINA BARB&.—-Synonyms: 
Ringworm of the beard ; Farasitic sycosts ; Barber's 
ttch ; Tinea barbe ; Sycosts parasitica. In the earli- 


PARASITIC AFFECTIONS, 51 


est stages of ringworm of the beard, the eruption 
does not differ essentially from that observed else- 
where on the body; there is first a small red point, 
which extends peripherally in circular form, while 
the center tends to clear, and becomes covered with 
a moderate amount of scaling. The eruption may 
remain in this condition without giving rise to much 
irritation, but in long standing cases, it occasions 
deep seated inflammation of the follicles of the 
part, with the production of boggy masses, corre- 
sponding to that condition just described as tinea 
kerion. | 

Diagnosis —TVhe sharply defined ring, or portion 
of a ring, which can often be made out, red and 
more or less scaly, with the history of an increase 
’ from a small point, indicates the character of the 
eruption, together with a discovery of the parasite 
by a microscopic examination of the scales and 
hairs. But the eruption may be confounded with 
eczema, true sycosts, seborrhea, and pityriasis, also 
possibly with fsoriaszs, acne, or syphilis. Eczema 
always manifests its character of an imperfectly de- 
fined margin, shading out into healthy tissue, and 
without the tendency to clear in the center, and 
generally exists elsewhere, or spreads out on to the 
neighboring parts. True sycosis presents single iso- 
lated pustules surrounding hairs, rather than the. 
large boggy masses of the parasitic disease. 

TINEA TRICHOPHYTINA CRURIS.—-Synonyms: 


62 MANUAL OF DISEASES OF THE SKIN. 


Ringworm of the thigh and genital region, Chinese, 
Burmese, and Tokeleau ringworm, Eczema margina- 
tum. The fourth and last variety of the eruption 
due to the presence and growth of the trichophyton 
tonsurans, is that about parts which are kept warm 
and moist, as in the genital region and axille, and 
presents features which at times render it very diffi- 
cult of recognition. But the development of the 
eruption here is the same as elsewhere; namely, 
from a small point which enlarges peripherally, with 
a tendency to clear in the center. When presented 
for treatment, however, one seldom sees small points 
or even rings; but generally there is a more or less 
reddened surface with a sharply defined margin, 
which is red, slightly elevated above the skin, and 
from which a few scales can be scraped. This mar- 
gin, which is generally not more than a line in width, 
is of a reddish color, while the surface behind is of 
a brownish, dirty yellow hue, sometimes quite red 
and inflamed from previous treatment; occasionally 
small, newly developing points will be found within 
the larger area or outside of the main line of dis- 
ease. On the male the eruption on the scrotum 
exactly corresponds to that upon the thigh; gen- 
erally the two thighs and the sides of the scrotum 
are affected unequally. In the region around the 
anus, and upon the buttocks where the parts come 
in contact, the eruptions on the opposing surfaces are 
seen to correspond to each other, and to present the 


PARASITIC AFFECTIONS. 53 


sharply defined margin, and soggy, perhaps HLS: 
tissue within. 

The itching from ringworm in the genital region is 
generally most intense, and the suffering may be 
very great. These cases often last a great length of 
time, being relieved by treatment but not cured 
until the accurate diagnosis is made. 

Diagnosts.—The eruption in this location is mainly 
liable to be mistaken for eczema, and tntertrigo; 
often the two eruptions are combined, either being 
first developed ; the sharply defined margin, and the 
more or less tendency to clear in the center, should 
always attract attention. Eczema in this region is 
worse towards the crotch, and tends to become 
lighter towards the periphery; simple chafing or 
erythema intertrigo has the eG of eczema in 
a lighter degree. 

Prognosis. —The prognosis of all the forms of ring- 
worm is good; there is a definite local cause, and if 
it can be removed the disease will surely get well. 
But the prognosis varies a good deal, with the form 
and location of the disease, and the individual pa- 
tient. Ringworm of the body always yields more 
or less readily. Onthe scalp and beard it frequently 
remains uncured for months and years, because of 
the great difficulty of reaching the parasite, deep in 
the follicles; in the genital region, if properly treat- 
ed, it is perfectly manageable. 

Treatment. —This is comparatively simple, al- 


54 MANUAL OF DISEASES OF THE SKIN. 


though the details are difficult of execution in some 
cases. A number of home remedies are of value in 
ringworm of the body, such as laying a penny wet 
in vinegar on the spot, ink, iodine, castor oil, etc. 
Any of the mercurial ointments, preferably the red 
precipitate or citrine ointment (Formule go, 92, 93, 
98), well rubbed in, will suffice for the removal of 
the disease on the body. Oleate of mercury in five 
or ten per cent. solution is also valuable, but there is 
a possibility of salivating with the too free use of it. 
Sulphurous acid, if thoroughly applied, is one of 
the best and most cleanly parasiticides; to be of 
value, however, it must be absolutely fresh, for by 
contact with the air a portion of the sulphurous acid 
evaporates, while the remainder is converted into 
sulphuric acid, which is irritating to the skin and 
useless to destroy the parasite. For this purpose 
an unopened package should be obtained, and a 
small bottle repeatedly filled therefrom. It is to be 
applied thoroughly to the skin, two or three times a 
day, undiluted, unless it appears too irritating, and 
the effect may be heightened by covering the part 
with oiled silk. Sometimes additional local stimu- 
lation is necessary, as with the compound tincture 
of green soap (Formula 39); if too much irritation 
has been set up, soothing treatment will be required. 
(Formulae 25, 26, 83, 84, 85). Ringworm in the gen- 
ital region is similarly treated. 

Ringworm of the scalp and beard, when recent, 


PARASITIC AFFECTIONS. 55 


may be removed by the means previously described, 
but when deep seated, it is very difficult for the 
remedy to reach the fungus in the follicles, and the 
extraction of the hairs becomes necessary. If, how- 
ever, we attempt to pull out the hairs from a tolera- 
bly well developed patch of ringworm, they break 
off, and considerable care will be necessary to insure 
their removal; they must be drawn perpendicularly 
to their axis, and repeated attempts will often be 
made before success is obtained. When depilation 
is practiced, it-is always well to rub into the sur- 
face afterwards a solution of bi-chloride of mercury 
(Formula 45) ; but this should not be intrusted to the 
patient, for serious accidents have been reported 
from the careless use of this remedy. In older 
patches, where the hairs have less tendency to 
break, and where large surfaces are to be treated, 
the method of wholesale depilation described under 
favus may sometimes be resorted to with advantage. 

The plan of destroying the parasite by inflaming 
the skin, which has recently found many advocates, 
consists in powerfully stimulating the scalp with such 
irritants as croton oil, repeatedly applied until an ar- 
tificial ‘zxea kerion is produced, and a muco-purulent 
fluid exudes; the loose hairs are then easily ex- 
tracted and the inflammation is allowed to subside 
under soothing treatment, when the disease is fre- 
quently found to be cured. This plan must be 
adopted with caution, as it is not safe to treat too 


56 MANUAL OF DISEASES OF THE SKIN, 


large a portion in this manner, and sloughing has 
occurred from its careless employment. 

‘The internal treatment of ringworm may be briefly 
disposed of.” As moss does,not grow upon the bark 
of perfectly healthy trees, with plenty of air and 
sunlight, so parasitic diseases seldom flourish upon 
individuals in perfect health, as has been repeatedly 
shown by failures in attempts at inoculation. It is 
always desirable, therefore, especially in cases which 
have lasted any length of time, to investigate most 
carefully the general health, and to prescribe intel- 
ligently therefor. Arsenic will not cure the disease, 
but may be required as a nerve tonic, or as an im- 
prover of nutrition, in connection with other reme- 
dies; the same may be said of many other agents. 
An eczematous habit or diathesis will often be 
found in ringworm cases; in eczema marginatum 
constipation aids the congestion and slight irritation 
of those parts which give the proper nidus for the de- 
velopment of the parasite; see treatment of eczema, 

Tinea favosa. Synonyms: Favus,; Porrigo fa 
vosa; Crusted ringworm ; Honcycombed ringworm. 

The second vegetable parasitic disease is due to 
the growth in and upon the skin of the achorion 
Schontleinit. This isa comparatively rare affection in 
this country ; it occurring only 31 times in our 8,000 
cases. The parasite may affect any and every part 
of the surface of the body, but is more commonly 


PARASITIC AFFECTIONS. 57 


seen or recognized upon the scalp. Hereit is really 
often severe and obstinate, because of the great size 
and depth of the hair follicles into which the fungus 
penetrates. Upon the rest of the surface, where 
there are no large hairs, the eruption is very super- 
ficial, and much more easily cured. The charac- 
teristic lesion of favus consists of a slightly raised, 
circular, cup-like mass, of a bright yellow sulphur 
color, commonly seated around a hair, with a de- 
pression in its center. When first appearing, the 
little cups are exceedingly minute, perhaps not 
much larger than the head of a small pin; but if left 
undisturbed, they may grow to the size of a quarter 
of an inch or more in diameter; they are easily 
dislodged, and the surface beneath presents a red, 
elazed appearance. The mass thus removed is found 
to consist entirely of the spores and mycelium tubes 
of the parasite, which may be readily recognized 
under the microscope, when ground up with a little 
water or glycerine, and magnified 300 diameters. 
But this characteristic cupped appearance of favus 
is not seen in every case as presented for treat- 
ment; more commonly there are yellowish masses, 
having somewhat the appearance of dried pus, 
around and among the hairs, which may become 
darkened by dust or blood. In cases which have 
existed for some time a large portion of the scalp 
may become affected, and exhibit the disease in 
various degrees of severity, in cups or simply dried 
ax 


58 MANUAL OF DISEASES OF THE SKIN. — 


scaling. This superficial development, however, 
is by no means the only portion of the disease; 
the parasite penetrates the hair and along its root- 
sheaths, so that when greatly affected, the hairs may 
be very easily extracted, and do not readily break 
off. The disease is far more destructive in its tend- 
ency than tinea capitis, and may not only destroy the | 
growth of the hair, but also the follicle itself, and 
the eruption may be followed by great cicatrization ; 
in old cases patches of scar tissue of greater or less ex- 
tent are always found, slightly reddened, and perhaps 
with some scattered hairs upon them. The disease 
always interferes very greatly with the nutrition of 
the hair, and renders it dry and harsh. 

Favus sometimes appears on other parts than the 
scalp, and if left undisturbed yellow cups will form, 
and around them there is generally a ringed, erythe- 
matous, scaly surface, very closely resembling ordi- 
nary ringworm. Inrare cases a large portion of the 
body may be affected with favus. Favus is always 
seen in those exhibiting ill health, and generally oc- 
curs in strumous subjects. It is questionable, how- 
ever, whether the disease itself, although purely a 
local one, has not something to do with lowering of 
the health and vitality of the individual. 

Diagnosis.—TVhis is not ordinarily difficult. No 
other disease exhibits the characteristic cups; and 
if doubt exists the microscope will always decide. 
Pustular eczema of the scalp, some cases of syphzlzs, 


q 


PARASITIC AFFECTIONS. 59 


and psorzasis are the only diseases with which it 
can be confounded. 

Treatment.—The treatment of favus differs with 
its situation ; upon the scalp, owing to the great size 
of the hairs and depth of the follicles, it is gener- 
ally most rebellious, unless the treatment. be very 
thoroughly and faithfully persisted in until perfectly 
cured. : 

Externalapplications if lightly applied are of very 
little service, because they will not penetrate the 
depth of the follicle; and although the external mani- 
festations are removed, it will crop out again when left 
to itself. Two methods of treatment are therefore 
applicable: the one of removing the hair and allowing 
the parasiticide to penetrate into the open follicles; 
the other of causing an inflammation, which, by its 
intensity, shall destroy the life of the parasite. De- 
pilation is most to be relied upon, and if thoroughly 
and efficiently performed is followed by success. 
The hairs may be extracted by the forceps, but this 
is a slow procedure when a large surface is involved ; 
and the methed recently employed by the writer for 
extracting the hairs ex masse is a much more ready 
and more certain method. ‘This consists in having 
sticks prepared of avery adhesive material (Formula 
20), which are made to adhere to the hairs, and then 
pulled off. The hair should be cropped to about one- 
eighth of an inch long, over the part to be treated ; 
the sticks are then melted on the end in aspirit-lamp, 


60 MANUAL OF DISEASES OF THE SKIN. 


and applied with a slight rotary or twisting motion, 
to work the short hairs into their substance. After 
they have cooled, they are removed by bending them 
over and pulling the hairs in succession, with a slight 
twisting motion. The sticks are prepared for fur- 
ther use by burning the hairs in the flame and wip- 
ing the end firmly upon a sheet of paper. 

After depilating by this or other means, a solu- 
tion of bi-chloride of mercury (Formula 45) is to be 
well rubbed into the skin by the operator. To be 
very effective depilation should be practiced every 
day or so until all the affected hairs are removed; 
it is well to give the patient an ointment (Formulz 
92, 93, 102), to be well rubbed into all the affected 
parts night and morning. 

In epidermic favus the cups are simply picked out 
and the surface well rubbed with pure sulphurous 
acid,.the “oleate of) mércury.5 "per -cent. or come 101 
the mercurial ointments (Formule 92, 93, 102). 
Most cases of favus should also have some internal 
treatment of a tonic character (Formule 52, 53, 58, 
59), in order that the general health may be raised 
to the standard which will resist the development of 
the parasite. 


Tinea versicolor. Synonyms: Prtyrzasis verst- 
color; Chloasma?,; Ltver-spots;. Chromophytosis. 
The third and last vegetable parasitic disease of the 
skin is that due to the presence of the mzcrosporon 


PARASITIC AFFECTIONS. OL 


furfur. This isseen first and mainly on the chest, in 
the form of yellowish-brown, slightly scaly patches 
of various sizes and extent. Sometimes the erup- 
tion consists of very many small points, at other 
times of patches which may cover a very considera- 
ble area. The back isalmost always affected at the 
same time, though toa less degree, and the eruption 
may occasionally spread under and upon the arms, 
and even upon the neck and face; and in rare cases 
upon the lower limbs. Usually it is quite symmet- 
trical; when there is much sweating the surface 
will be almost free from scales, and may be quite 
red. There is often slight itching accompanying it. 
Upon scraping the patches and placing the scales 
beneath a microscope, groups or masses of round 
spores are seen and more or less mycelium among 
the epidermal scales. 

This eruption has considerable tendency to recur, 
and in many cases it lasts for years, being partially 
removed by treatment, and then relapsing, owing to 
the failure to entirely reach and destroy the para- 
site. 

Diagnosis.—This is comparatively easy; the erup- 
tion may be mistaken for chloasma, leucoderma, 
ringworm,- erythematous eczema, and _ seborrhea, 
This eruption was formerly called chloasma, but this 
term is now given to a pigmentary affection, having 
no connection with the one now described, nor has 
the present eruption any connection with liver dis- 


62 MANUAL OF DISEASES OF THE SKIN. 


ag 


order. True chloasma occurs on the face, and sel- 
dom, if ever, in a manner to resemble tinea versi- 
color. In leucoderma there are white patches upon 
a yellowish or brown base, whereas in the parasitic 
disease now described we have yellow patches upon 
a normal skin. Seborrhcea of the chest presents cir- 
cular patches, which are more red in color; the 
scales are very greasy, and the parasite is not found 
under the microscope. : 

Treatment.—The treatment is often ineffectual in 
permanently removing the eruption, because not 
persisted in long enough. It consists of the appli- 
cation of a parasiticide, of which there are many of 
value. Sulphurous acid in solution will remove the 
eruption very quickly, also Vlemingkx’ solution 
(Formula 37), and a few sulphur vapor baths will aid 
greatly; preparations of mercury, as the oleate, 
citrine ointment diluted, and others, are also effec- 
tual; also solutions of corrosive sublimate, four 
grains to the ounce, with a little ammonia; like- 
wise tarry preparations, well rubbed into the skin, 
such as the compound tincture of green soap, or 
the liquor picis alkalinus (Formule 39, 40, 42). It 
is also well to have the patient wash the surface very 
freely, and for this purpose even yellow bar soap 
may be used to advantage. 


~ 


CTIA? i AV EER 


CLASS I. MORBI CUTIS PARASITICI.—PARASITIC 
_ AFFECTIONS—(Continued.) 


Animal Parasitic A ffections. 


Two distinct diseases of the skin are recognized 
as due to animal parasites, although there are a 
number of parasites which may at times attack the 
human integument. These two principal ones are 
phthiriasts and scabies. 


I. Phthiriasis. Synonyms: Pediculosis ; Morbus 
pedicularts ; Lousiness. YVhree distinct forms of 
pediculi are found upon the human skin, occupying 
severally and chiefly the body, the head, and the 
pubis. Hence we speak of three forms of this affec- 
tion or condition, namely, phthirtaszs corports, phihi- 
riasis capitis, and phthirtasis pubts. 

PHTHIRIASIS CORPORIS.—The body louse has as 
favorite seats of occupation the regions about the 
shoulders and hips, and here the greatest number of 
skin lesions will be usually found. These consist of 
inflamed and torn papules of various sizes, together 


with abundant scratch marks or excortations. There 
°63 


64. MANUAL OF DISEASES OF THE SKIN. 


is also a curious lesion seen, which is caused by the 
manner in which the insect obtains its nourishment ; 
this consists of a very minute red point, not elevated 
above the surface of the skin, and isin reality the end 
of a small plug of blood occupying a dilated follicle, 
into the bottom of which the insect has penetrated 
with its proboscis in order to suck blood. On strip- 
ping the patient with phthiriasis corporis, one gen- 
erally finds none of the’ parasites upon the body, 
but they may commonly be found in the folds of 
the clothing about the parts affected, and here like- 
wise are laid the eggs or nits, which may be seen by 
careful inspection, as minute, oval, whitish bodies, 
adherent to the fibres of the clothing. In debilitated 
subjects and in long standing cases the itching may 
give rise to so much scratching that very considera- 
ble lesions result; even ulcerated points, covered 
with thick crusts. 

PHTHIRIASIS CAPITIS exhibits many of the re- 
sults of scratching and inflammation upon the scalp, 
in the form of excoriations covered with more or less 
crusts. The itching is generally quite considerable, 
and the patient unconsciously tears off the crusts, 
continually making the eruption worse. In severe 
cases a large portion of the scalp may be the seat of 
inflammatory action, and the hairs, accordingly, may 
be matted together by the exudation; the glands of 
the back of the neck become enlarged, and the scalp 
emits a fetid odor. The pediculi may generally be 


PARASITIC AFFECTIONS. 65 


seen moving upon the hairs, and their nits are found 
attached to the same. 

PHTHIRIASIS PUBIS.—The true cause of itching 
about the pubis will sometimes pass long unrecog- 
nized. In some cases there will simply be a moderate 
amount of itching about the genital region, with 
the occasional development of scratched papules, 
but in other instances all these parts may be very 
much torn, and a considerable eruption exist. The 
pediculus pubis or crab louse differs from the preced- 
ing varieties in being much smaller and more round; 
it holds very firmly by means of its crab-like claws 
to the hairs, and is generally found firmly attached 
to the hair, near its exit from the follicle, and with 
its body in close contact with the surface. Thus it 
may readily escape recognition, and appears more 
like, a little: scab or erust .than,.a ‘living |insecti 
When it is dislodged, it still holds firmly to the 
hair, and is with some difficulty removed. It de 
posits its eggs or nits upon the hairs of the part, 
and generally they can be found, as minute white 
specks, attached to them. This crab louse may 
also infest the hairs of the axille, eyebrows, eye- 
lashes, and even the hairs of other parts, as the 
beard. 

Diagnosis —Upon the scalp the eruption resem- 
bles eczema, pustular syphilis, and possibly psorz- 
asis; but the inflammation caused by lice, and the 
resulting crusts and the itching, are generally far 


66 MANUAL OF DISEASES OF THE SKIN, 


greater than those in these eruptions. In some 
cases, however, very few lesions will be seen, and 
the scalp may be kept so clean that no pediculi 
can be discovered. But, however great care is exer- 
cised, some nits may almost always be found on the 
hairs when the eruption is due to lice.. Phthiriasis of 
the body may be mistaken for many eruptions, ec- 
zema, Scabies, pustular syphilis; also for pruritus and 
prurigo; but the peculiar locations of the principal 
lesions over the region of the shoulders and about 
the loins should excite suspicion; and a careful ex- 
amination ‘will generally reveal the marks of the 
finger nails in the torn papules and streaks, and 
great care will reveal the hemorrhagic specks al- 
luded to. Phthiriasis pubis may also resemble sim- 
ple eczema and scabies;. but the finding of the 
parasite renders the diagnosis clear. 

Many of the cases of phthiriasis of the body and 
genital regions were formerly called pruritus and 
prurigo; these terms, however, belong to entirely 
distinct diseases; pruritus, or itching, isa symptom 
of phthiriasis, as also of many other skin affections. 

Treatment.—For phthiriasis of the scalp simple 
cleansing alone does not suffice, but some agent 
must be employed which is directly a parasiticide. 
The most effective and sure application is that of 
ordinary petroleum or kerosene oil, the commoner 
the better, as it contains a larger proportion of the 
volatile elements, which are destructive to the life 


PARASITIC AFFECTIONS. 67 


both of the parasite and its nits. The head should 
be thoroughly soaked with it two or three times 
during a day, and left wrapped up in a cloth for 
twenty-four hours. At the end of this time it is 
thorcughly washed, and if there are any excoria- 
tions, they may be treated with a little zinc or white 
precipitate ointment (Formule 83, 84, 85, 91.) One 
such thorough application is generally sufficient for 
the complete cure of the disease; the nits will then , 
be found to be loosened upon the hairs, and to come 
out with tolerable readiness; it is never necessary 
to cut the hair in these cases. Other treatment may 
be used, as an infusion of stavesacre, as also white 
precipitate ointment in ful] strength. Lotions of bi- 
chloride of mercury should not be entrusted to pa- 
tients for this purpose, as they are more or less 
dangerous. 

Phthiriasis corporis is very easily remedied. The 
patient is simply to take a warm bath with soap and 
- water, after which fresh clothes, which have been 
thoroughly boiled and ironed with extra care, are 
put on; the parasites adhering to the clothing are 
thus removed, and the clothes which are taken off 
should be thoroughly baked or boiled. Some care 
should also be exercised that other articles of cloth- 
ing which the patient has worn be similarly treated, 
lest lice develop anew from the nits attached to 
them, however carefully removed from other gar- 
ments. 


68 MANUAL OF DISEASES OF THE SKIN. 


Phthiriasis pubis is sometimes a little difficult of 
removal because patients do not make sufficiently 
thorough applications. Any of the mercurial oint- 
ments (Formule 90, 92, 93) are quite sufficient for 
the destruction of the parasites, as also ammoniated 
mercury well dusted on; the danger of salivation 
should always be borne in mind when the simple 
unguentum hydrargyri is employed. In very rare 
cases it is necessary even to shave the parts affected 
with pediculi pubis; but this need seldom be the 
case if care is exercised. 

It need hardly be stated that none of the varieties 
of pediculi can by any possibility appear beneath 
the skin, or affect the system at large, as is so often 
popularly supposed. They are air-breathing insects, 
and remain wholly upon the surface of the body, 
and the lesions caused are due to the irritation from 
them and the consequent scratching. 


2. Scabies. Synonym: The ztch. _ This affection, 
quite different from the conditions just described, 
is due to the boring into the skin or rather beneath 
the epidermal layer, of a minute insect, the acarus 
or sarcoptes scabiet. The female does the mischief, 
she burrowing for the purpose of laying her eggs, 
which may be found in a little track which she 
leaves behind her, called the cumnzculus or furrow. 
The male is said never to penetrate the skin. This 
little track which the female leaves forms the path- 


PARASITIC AFFECTIONS. 69 


ognomonic sign of the disease ; it consists of aminute 
brownish black line, generally curved, which appears 
as though a bit of dark colored sewing silk had been 
run beneath the surface. If the skin is washed or 
wiped, this, instead of being removed, will stand out 
still clearer, and will be seen to terminate at a point 
of inflammation, a papule, vesicle, or pustule, or to 
pass over the surface of one of these. The point of 
inflammation is caused by the presence of the insect, 
and she will be found at that extremity of the cumz- 
culus or furrow ; behind her a number of oval eggs 
in various degrees of development may be observed 
microscopically, and between them minute black 
particles, which latter are supposed to be the faces 
of the insect. Very recent cases may not present 
cuniculi, if time has not elapsed for a sufficient bur- 
rowing of the insect, but papules or vesicles may 
form immediately on her penetrating the epi- 
dermis. ~ 

The lesions of scabies are peculiarly multiform, 
exhibiting papules, vesicles, and pustules often of 
some size, also scratch marks and crusts, each case 
varying greatly according to its duration and the 
condition of the individual in regard to health, 
cleanliness, etc. In light cases, or in very healthy 
subjects, papules predominate, with a few vesicles 
when the skin is delicate; whereas in broken down 
constitutions and in children, very severe inflam- 
matory lesions may result, with large pustules; or, 


70 MANUAL OF DISEASES OF THE SKIN. 


these may be scratched, and large, superficial, raw 
patches form, covered with more or less crusts. 
There are certain places of predilection which aid 
very greatly in recognizing the disease. The first in 
importance is the region about the fingers, especially 
where they join on the back of the hand; next, on 
the inner surface of the wrists, also the soles of the 
feet, and about the malleoli in children. In males 
there will almost invariably be found one or more 
lesions about the penis and scrotum, partaking of 
the, same inflammatory character; and often cuni- 
culi or furrows of the insect may be found here very 
perfectly developed. In the female the region of 
the nipple is very often affected, also the flexor sur- 
face of the forearm and the fold in front of the axilla 
in both sexes; the face and head generally escape. 
The itching of scabies may be quite severe, but is 
generally of a mild form, and bearable; it is even 
pleasant compared to that in severe eczema. There 
will almost always be found the history of contagion 
in scabies, and rarely will one member of a family 
be attacked alone, especially if there are children. 
Scabies is becoming a comparatively rare disease 
in this country; among the 8,000 cases analyzed it 
only formed 0.39 per cent. in private, and 2.18 per 
cent. in public practice. Occasionally it appears in 
public institutions, and many cases are seen together, 
and the disease may be difficult to eradicate. In 
some countries, as in Scotland, it is much more fre- 


PARASITIC AFFECTIONS. 71 


quently met with, and in statistics from Glasgow it 
forms about twenty-five per cent. of all cases of skin 
disease. During our late war it was quite common, 
and was often spoken of as the “ army itch.” 
Diagnosis—As may be judged, the eruption of 
scabies may be confounded with very many affec- 
tions of the skin; eczema, lichen, phthiriasis, pru- 
rigo, pruritus, and urticaria papulosa,; between pap- 
ular and vesicular eczema of the hands, and mild 
recent scabies, the diagnosis is often very difficult. 
Prognosis—This is good; of however long stand- 
ing, the disease may be rapidly and thoroughly 
cured if proper and complete treatment is carried 
out. The system is never affected, and there is no 
harm in removing the disease as quickly as possible. 
Treatment.—This is accomplished purely by ex- 
ternal means. As an indication of the plan to be 
followed we may mention the rapid cure of the dis- 
ease practiced in the Hépital St. Louis, in Paris. 
The patient is first very thoroughly rubbed all over 
from head to foot with soft soap, especial attention 
being paid to the regions most apt to be affected: 
this process occupies about half an hour. The pa. 
tient then takes a warm bath, remaining in it for 
half an hour or so, in the meantime scouring the 
skin thoroughly. On coming out of the bath, he is 
thoroughly rubbed from head to foot with an oint- 
ment containing sulphur (Formule 100, 101), and this 
process also takes half an hour at least, particular 


Ne 


72 MANUAL OF DISEASES OF THE SKIN. 


-attention being given to the portions mentioned as 
most commonly affected. The clothes, which have 
been thoroughly baked while the patient was in the 
bath, are now put on, and it is expected that the 
disease*is thus entirely cured. The idea of the first 
friction is to open the furrows, as far as possible re- 
moving the eggs which would hatch out; these, 
with the male insect which could be thus reached, 
the bath then removes from the skin. The sulphur 
ointment being then thoroughly rubbed into all the 
parts, enters the open cuniculi and completes the 
destruction of the insects. The clothes having been 
baked at a high temperature, all the insects which 
may have lodged upon them are destroyed. 
Sometimes cases of scabies are over-treated, or 
are so severely irritated by the measures used for 
the destruction of the parasite, that an artificial 
papular eruption results, which more or less imitates 
the disease. In such cases a soothing treatment 
may be employed for a few days, such as is suitable 
for an eczema, and the case is then left a little with- 
out treatment. If there are still the elements of 
scabies remaining they will then become apparent. 


CHAPTER RGhX: 


CLASS II. MORBI GLANDULARUM CUTIS.—GLANDU- 
LAR AFFECTIONS. 


THE diseases belonging to this group are divided 
into two classes, namely: those relating to the 
sebaceous glands, and those affecting the sweat 
glands. 

The diseases of the sebaceous glands comprise six 
distinct varieties, several of which may often be 
found more or less associated in the same individ- 
ual. Of the sebaceous diseases we find two orders: 
First, those due to faulty secretion or excretion of 
the glands: acne sebacea, acne punctata, acne mol- 
luscum ; and second, those exhibiting inflammation 
of the sebaceous glands with the surrounding tissue: 
acne simplex, acne indurata, acne rosacea. 


1. Acne sebacea. Synonyms: Seborrhea,; Se- 
borrhagia,; Steatorrhea,;, Fluxus sebaceus. Three 
distinct forms of this variety of functional sebaceous 
disorder are recognized: acne sebacea, or seborrhea, 
oleosa, cerea, and cornea. 

ACNE SEBACEA OLEOSA.—In this the skin is more 
oily than natural, and has a greasy, shiny appear- 

4 ao 


74 MANUAL OF DISEASES OF THE SKIN. 


ance. When the scalp is affected the hair has an 
unctuous appearance, and emits a nauseous odor. 
Upon the face and the forehead it may exist to such 
an extent that the oily secretion will stand in drops 
upon the skin. 

ACNE SEBACEA CEREA.—This dry form of sebor- 
rhoea is characterized by the presence of greasy 
masses of scales or crusts, of a yellowish or greyish- 
brown color, which tend to adhere. to the skin. 
Upon the nose and cheeks it may present a very 
disagreeable and annoying coating: upon the scalp 
the secretion may either remain quite greasy and 
accumulate, so that it can be removed as a yellow- 
ish, crusty mass, with the finger nail; or, it dries into 
scales, which fall continually upon the clothing, and 
thus constitutes a large share of the cases ordinarily 
called dandruff or dandriff. Commonly a large por- 
tion of the scalp is affected, and loss of hair ensues 
to a greater or less extent. Seborrhcea of the scalp 
often resembles closely a dry scaly eczema, a pityrt- 
asts, or psoriasis. 

ACNE SEBACEA CORNEA is characterized by the 
development, principally upon the face, of horny 
sebaceous masses and concretions which, when forci- 
bly removed, are found to have projections into the 
orifices of the sebaceous glands ; sometimes their re- 
moval causes slight bleeding. This condition may 
remain, especially on elderly persons, for a length of 
time, and may result in epithelioma. 


GLANDULAR AFFECTIONS. 75 


Treatment.—The constitutional treatment of these 
functional subaceous disorders is essentially that of 
inflammatory acne to be described later. Locally 
stimulating and astringent applications are called 
for; on the scalp tannin and white precipitate oint- 
ment (Formule 87, 90, 91) are most serviceable, with 
an occasional shampoo with tar soap, or green soap 
in solution (Formula 38); later, mildly stimulating 
lotions are called for, and still later those with 
cantharides (Formule 49, 50, 51). The local treat- 
ment of seborrhcea of the face is practically that of 
the other forms of acne; with the addition of a bis- 
muth and white precipitate ointment (Formula 91). 


2. Acne punctata. Two forms of disease are rec- 
ognized which are due to retention of the sebaceous 
matter, namely: acne punctata nigra, or comedo, and 
acne punctata albida, or milium. 

ACNE PUNCTATA NIGRA, or comedo, represents 
the little black specks seen upon the face, commonly 
called black-heads, worms, or grubs. These consist 
of hardened plugs of sebaceous matter contained 
within the cavity and ducts of the glands; the black- 
ened end is probably due to dust from the atmos- 
phere, although this has been disputed of late. 
The foundation for the popular idea that these 
plugs, which can be squeezed out, are themselves 
worms or insects, lies in the fact that there is in 
reality a very minute animal which infests the se- 


76 MANUAL OF DISEASES OF THE SKIN. 


baceous glands; it is, however, by no means of such 
a size as one might imagine. It is called the demo- 
dex or steatozodn folliculorum, and is exceedingly 
small, being in length from ;4, to ¢, of an inch, 
and in breadth about z1, of an inch; but this ani- 
mal is perfectly harmless and: entirely innocent of 
the disease; a number may be found in a single 
plug, or again several masses may be examined 
without finding one. 

ACNE PUNCTATA ALBIDA.—Synonyms: Milium,; 
Grutum, Strophulus albidus. Milia are the little 
white specks or bodies often seen in the neighbor- 
hood of the eyes, and upper part of the face, and 
occasionally on other parts of the body. They con- 
sist of small collections of. sebaceous matter, which 
may have undergone alteration and calcification, 
situated beneath a very thin layer of skin; they 
cannot be squeezed out, as can comedones, and do 
not always come out, even when the skin is punc- 
tured over them. 

Treatment.—Comedo calls for the internal and 
external remedies suitable for ordinary acne, and in 
addition the expulsion of the contents of the glands 
by means of firm pressure made over them by 
means of a small tube with rounded edges and an 
aperture of sufficient size to admit the plug. 


3. Acne moliluscum. Synonyms: Molluscum se- 
baceum; Molluscum contagiosum. Some little dis- 


GLANDULAR AFFECTIONS. 77 


pute has arisen with regard to the real nature of 
this disease, but the weight of evidence seems still 
to connect it with disorders of the sebaceous glands. 
It is, however, quite a rare affection, and is seldom 
associated with the other forms of sebaceous dis- 
ease. It is more common in children than in adults. 
It consists of small, pearly, or slightly reddened, 
globular masses, projecting a little from the skin, 
generally with an opening in their center, from 
which can be squeezed a cheesy or milky substance. 
Their common seat is about the face, eyes, and tem- 
ples, although they may be seen on any part of the 
body, as on the shoulders and back, and about the 
genital region. 

These little lesions often appear to be contagious, 
hence the name, molluscum contagiosum; but the 
real cause of the contagion has never been demon- 
strated, and inoculations have generally proved 
fruitless. The prognosis is good, as they may SONG 
rally be quickly and easily removed. 

Treatment.—This consists in removing the little 
tumors with the curved scissors, the base being 
afterward thoroughly burned with a stick of nitrate 
of silver. 

SEBACEOUS CYSTS or wens belong in this group, 
and appear as small, globular, movable tumors, with 
semi-fluid contents, projecting slightly above the 
surface, covered with normal or slightly reddened 
skin. It is not sufficient to evacuate their contents, 


78 MANUAL OF DISEASES OF THE SKIN. 


as the sebaceous sac will pretty certainly refill; they 
should be removed entire or enucleated, or when 
already opened, the sac can be drawn out with the 
forceps, and by a little care can be entirely re- 
moved. 


The next three varieties of acne are due to in- 
flammation of the sebaceous glands and surround- 
ing tissue, namely, acne simplex, acne indurata, and 
acne rosacea. ‘These, although defined and classified 
as separate eruptions, are really but varieties of one 
and the same affection, and their nature and treat- 
ment will be considered together; they are also 
very closely associated with the two forms of acne 
first described. ‘These five varieties of sebaceous 
diseases are constantly seen variously intermingled, 
and occasionally all of them may be distinctly made 
out on the same individual. 


4. Acne simplex. Synonyms: Acne vulgaris ; 
Acne disseminata,; Acne juventlis.. Vhis represents 
the eruption commonly seen upon the faces of 
young people, consisting of scattered papules or 
pustules, generally associated with the black points 
of acne punctata, or comedones. ‘Yhe disease pre- 
sents different degrees of severity in different sub- 
jects, from a few, irregularly scattered papules or 
pustules, to a very badly marked face. The nature 
of the disease is undoubtedly inflammation about 


GLANDULAR AFFECTIONS. 79 


sebaceous glands, which is generally the result of 
hardened sebum retained in them; often the end of 
the sebaceous plug will be seen in the center of an 
inflamed point, which subsides as soon as it is ex- 
pressed. Quite as often this is not seen externally, 
but the cavity of the gland is blocked, and when 
the point is freely opened a minute solid mass 
escapes with the blood and pus. 


5. Acne indurata. This name is given to cases 
where the lesions are larger, forming indurated mass- 
es, from the size of a small pea even up to that of a 
small chestnut, generally of an indolent character, 
purplish, and slow to suppurate. While the acutely 
tender points of acne simplex have to do, as a rule, 
with but a single blocked and inflamed gland, in 
acne indurata a series. of glands and circumscribed 
masses of tissue are involved, and the single ele- 
ments partake rather of the characteristics of dermic 
abscesses than of the lesions ordinarily recognized 
as acne. These are often very indolent, lasting 
weeks or months, and giving little or no pain upon 
pressure; as a rule they have not pustular sum- 
mits, but require to be lanced before pus is discov- 
ered; when they are opened the contents are found 
to be of a grumous character, and sometimes fetid. 


6. Acne rosacea. Synonyms: Gutta rosea ; Cou- 
perose. The preceding forms of acne are almost al- 


80 MANUAL OF DISEASES OF THE. SKIN. — 


Ways seen in young persons, whereas this form of 
sebaceous disease belongs to older periods of life. 
The characteristic location of the eruption is about 
the central portion of the face included ina line 
dropped from the external angles of the eyes to the 
chin; the surface is more or less evenly reddened, 
perhaps with some dilated blood-vessels, and with 
many or few separate papules or pustules. There is 
a heat and burning in the part, with redness and 
flushing upon the slightest excitation, also after eat- 
ing and drinking, or on entering a hot room. 

Acne simplex and indurata may affect the back, 
shoulders, and chest, as well as the face, and in some 
instances may cause very great scarring ; acne rosa- 
cea affects only the face. 


Diagnosis.—While it is usually easy to recognize 
acne, in certain instances the diagnosis may be diffi- 
cult. Acne simplex may resemble a papulo-pustular 
syphiloderm, papular eczema, tmpetigo, and also erup- 
tions produced by zodzue and bromine, acne indurata 
may be mistaken for a tubercular syphiloderm and 
furunculus ; and acne rosacea is sometimes difficult 
to distinguish from an erythematous and papular 
eczema, a flat tubercular syphiloderm, and lupus 
erythematosus and vulgaris. 

Etiology.—The causes of acne are found always in 
a lowered vitality, very commonly associated with 
constipation and assimilative disorders, and in fe- 


GLANDULAR AFFECTIONS. SI 


males with sexual disturbances. Acne frequently 
improves greatly after marriage, although it is not 
rare to find quite severe cases in those who are mar- 
ried and have had children. 

Treatment.—To be successful, the treatment of 
acne must embrace both constitutional and local 
measures. The constitutional treatment includes _ 
dict, hygiene, and internal medication. Certain ar- 
ticles of food almost invariably produce acne in 
some individuals; the articles having this special 
tendency are, buckwheat, pastry, hot bread, nuts, 
cheese, chocolate, fried substances, and excess of © 
sweets and starches; it is generally necessary to cut 
off many of the so-called luxuries of life: among 
them, wines and beer, also sweet and rich articles of 
food. Exercise is all-important, and the proper care 
of the skin by bathing and otherwise, must never be 
neglected. 

There is no one internal remedy which will have 
any great and permanent effect upon all cases of 
acne; arsenic will not cure the disease. The meas- 
ures to be used are those directed principally to 
the restoration of perfect health, and tothe removal - 
of assimilative and nutritive debility often shown by 
constipation and dyspepsia, and sexual distubances. 
The constipation is to be met by measures which in- 
duce healthful activity of the chylopoiétic viscera, 
and not simply by repeated pugatives or by min- 
eral waters; the pill of aloes and iron (Formula 

4* 


85 MANUAL OF DISEASES OF THE SKIN. 


66) will be found of great service, if used care- 
fully and intelligently, as described in connection 
with eczema. For the dyspepsia, the most varied 
measures may be required; a cup of hot water, 
taken half an hour before eating, will often be of 
the greatest assistance. In a large number of 
cases of acne, however, alkalies will be found to 
yield the best results, combined with various vege- 
table remedies (Formule 53, 55, 56, 57). Ina 
certain number of cases, the acne will depend 
almost entirely upon pure debility, and powerful 
tonics will be called for (Formule 52, 58, 59). Ar- 
senic may act as an adjunct, later in the treatment 
of the disease; but it is almost useless to give it 
until other elements have been treated. In some 
cases uterine disturbances will seem to be the cause 
of the continuance of the eruption, but in quite a 
share of these instances the removal of the portal 
congestion, which may give rise to both the uterine 
derangement and the acne, will be all sufficient to 
remove the disease. 

The local treatment of acne is varied, and ofttimes 
the measures which are suitable to one case will 
prove harmful or of no avail in another. If stimu- 
lation is resorted to, it should be active, sharp, and 
perfect, followed by suitable soothing remedies. 
In a large share of the cases, slightly astringent 
and soothing lotions will be found of the greatest 
service (Formule 33, 34, 35, 36); it is well where 


GLANDULAR AFFECTIONS. 83 


there is much inflammation, to begin with a very 


~ mild application (Formule 25, 26), using the sul- 


phur preparations when in a less active condition. 
The greatest benefit is observed in all the inflam- 
matory forms of acne from the local use of very hot 
water, conjoined with other treatment. The water 
should be employed as hot as the face can bear, ap- 
plied by means of a handkerchief; this is dipped in 
the water and held for a few moments to the part, 
the operation being repeated two or three times, 
lasting altogether not more than from three to five 
minutes; after this the suitable lotion is applied 
and left on all night. The hot water should be used 
but once a day, but the lotions or other applications 
may be kept freely applied with advantage. Much 
gain can also be had by removing the comedo plugs 
as described, and freely lancing all the inflamed 
points, the bleeding being encouraged by bathing 
with tepid water; a single thorough operation can 
accomplish more than a week or two of other local 
treatment. Where the disease is indolent, stimula- 
tion is required, as with caustic potassa (Formula 16), 
followed by a soothing ointment, as of zinc (For- 
mulz 83, 84). It is also advantageous to touch the 
spots carefully with the acid nitrate of mercury. 


DISEASES OF THE SWEAT GLANDS. 


Three varieties of disorder of the sweat glands 
are recognized; 1. As to quantity of secretion; 


84. MANUAL OF DISEASES OF THE SKIN. 


2. As to quality of secretion; and, 3d. With reten- 
tion of secretion.. The quantity of secretion may 
be either augmented or diminished; to the former 
state the name of hyperidrosis, and to the latter 
anidrosts is given. 


1. Hyperidrosis. Synonyms: Ephzdrosis ; Exces- 
sive sweating. This condition may be either general 
or partial; general sweating is observed in certain 
cachectic diseases, as phthisis, with which dermato- 
logy has little to do.’ The local forms of sweat- 
ing are very annoying at times, and are frequently 
presented for treatment; the most common loca- 
tions are the palms and soles, and axille, although 
other parts of the body may be affected. Hyperi- 
drosis of the palms is readily recognized; on the 
feet, however, the condition may be quite peculiar. 
The patient will complain of tenderness of the soles, 
with more or less burning, which may increase to 
such an extent that walking and standing become 
very painful. The sole and the region of the toes is 
seen to be reddish or pink, and to have a soddened 
condition; not much moisture can usually be found, 
as it is readily absorbed by the socks and shoes. 

Ltwology.—The true causes of increased sweating 
are not determined, but there is little doubt that it 
always indicates debility, and generally of a nervous 
form. | 

Treatment.—This is both internal and local; in- 


GLANDULAR AFFECTIONS. 85 


ternal treatment should include every measure cal- 
culated to restore nervous and general vigor, es- 
pecially including strychnine, quinine, and arsenic. 
There is one remedy which has been found to exer- 
cise a very marked control upon the secretion of 
sweat, but which has to be used with caution ; this 
is atropine given internally, and I have seen ;j;th 
of a grain at a dose exhibit this power to a striking 
degree. After a time, however, it seems to lose its 
effect. Sulphuric acid alone, or administered with 
quinine is also of very considerable service. 

The local treatment consists of astringent reme- 
dies, and the local application of belladonna; for 
sweating of the hands a certain amount of benefit 
can always be obtained by rubbing half a teaspoon- 
ful of the tincture’well into the palms. Excessive 
sweating of the feet can very commonly be con- 
trolled by a thorough and constant application of 
the unguentum diachyli (Formule 94, 95); this 
should be spread on muslin and worn upon the soles 
night and day continuously for a period of at least 
from ten days to three weeks, the dressings being 
changed once or twice daily. Foot baths of infu- 
sion of white oak bark, also powders containing sali- 
cylic acid (Formula 79), well rubbed into the soles 
and sprinkled in the socks, are of service. 


2. Anidrosis. Diminution or arrest of sweating 
is indicated by a dry, harsh state of the skin (xero- 


86 MANUAL OF DISEASES OF THE SKIN. 


derma), with more or less exfoliation. It is found 
in certain cachectic diseases, as in chronic nephritis 
and cancer, also in ichthyosis, and in general chronic 
eczema; it is likewise sometimes presented for treat- 
ment unconnected with any other apparent disturb- 
ance of health. No cause is known. The patient 
should always be treated in accordance with indica- 
tions present, as with tonics, more or less alkalies, 
and the best diet and hygiene. Alkaline baths (For- 
mulz I, 2, 3), followed by inunction with oils, the 
elycerite of starch, or cosmoline (Formula 104), will 
generally succeed in relieving the condition, though 
very often perfect restoration of the skin to a 
healthy condition is almost impossible. 


3. Bromidrosis. Synonyms: Osmidrosis; Offen- 
sive sweating. This is generally associated with the 
first variety of sweat disorder, namely, hyperidrosis ; 
although sometimes there will be an unnatural odor 
to the perspiration without any apparently great 
increase. The entire body may emit an offensive’ 
smell, but more commonly this is confined to cer- 
tain locations, more particularly the feet, axilla, and 
genital regions. The same measures which are of 
value in excessive sweating, are generally of service 
in this condition. 


4. Chromidrosis. Synonym: Colored sweating. 
This is a curious state, which has been described by 


GLANDULAR AFFECTIONS. 87 


a number of observers, but it is exceedingly rare. 
‘ Blue and yellow sweat have been recorded, and a 
number of instances where the sweat appeared red. 
This latter condition, however, is in reality due toa 
hemorrhage from the sweat glands, and will be de- 
scribed under hemorrhages, by the name of hematt- 
drosts. Nothing is known with regard to the etiol- 
ogy, and little with regard to the treatment of 
chromidrosis. These cases have usually. been ob- 
served in nervous and hysterical subjects, generally 
females, and there is strong reason to believe that 
in some of the instances deception has been prac- 
ticed. 


5. Dysidrosis. Some ten years ago Dr. Tilbury 
Fox described, under this name, what he regarded as 
a peculiar disease, which he believed to be due to re- 
tention of the sweat within the ducts of the follicles, 
giving rise to vesicles. The condition was observed 
most frequently upon the hands, and especially upon 
their backs and between the fingers. The lesions 
were described as minute vesicles, very deeply seated, 
and without the surrounding inflammation seen in 
eczema and scabies. Appearing when fully devel- 
oped like minute grains of boiled sago beneath the 
skin, in rare cases this condition continues and in- 
creases to such a degree as to form bullz of some 
little size; there is always more or less itching with 
the disease. Shortly afterward Mr. Jonathan Hut- 


88 MANUAL OF DISEASES OF THE SKIN, 


chison described under similar terms, an affection 
to which he gave the name of cheiro-pompholix 
(See Pompholix), and one of the cases which was ~ 
figured in his atlas was also one of those upon 
which Dr. Fox had based his description of dys- 
idrosis. Discussion has followed and the subject is 
by no means yet definitely settled. In regard to 
certain of these cases there is little doubt but that 
such a disease as dysidrosis really exists, consisting 
of the closure of the sweat follicles and retention of 
sweat within them. This condition may be ob- 
served on the hands in warm weather, also upon the 
tips of the fingers at other times; it is likewise seen 
about the face as a more chronic affair. Those 
points upon the face especially may last for a very 
considerable length of time; when punctured they 
give exit to a clear, serous, alkaline fluid. 
Diagnosis.—This is sometimes very difficult to es- 
tablish; the eruption especially resembles vesicular 
eczema, scabies, and pompholix. 
Treatment.—Dysidrosis seems to be very definitely 
connected with nervous depression, and the cases 
are always more or less controlled by the internal 
administration of arsenic. Other remedies may also 
be called for to meet indications, inasmuch as dys- 
pepsia and other conditions may possibly give rise 
to the eruption. Locally there are no particular in- 
dications for treatment other than those called for 
-by the state present. In some cases a considerable 


GLANDULAR AFFECTIONS. 89 


amount of inflammation attends the disease, when 
soothing and astringent lotions (Formule 25, 26) are 
motrreal service. In the more. chronic cases, the 
diachylon ointment (Formule 94, 95) spread on lint 
and kept upon the parts will assist greatly in check- 
ing the progress of the disease 


6. Sudamina. Synonym: Milzaria. By this term 
is indicated an acute affection of the sweat glands, 
characterized by retention of secretion, which is seen 
especially in connection with certain febrile condi- 
tions. It is most characteristically exhibited upon 
the abdomen during the course of typhoid fever and 
rheumatism, as minute vesicles with a very delicate 
covering’ “and perfectly “clear contents ;* there is 
usually no inflammation around them, and they ap- 
pear studding the surface as though very small 
drops of water had been sprinkled upon it. The 
condition is one which calls for little or no treat- 
ment. 


CHAGAE RY: 
CLASS III. NEUROSES.—NEUROTIC AFFECTIONS. 


THERE are six affections of the skin which are 
classed as neurotic, because in them a nerve element 
largely predominates; these are zoster, pruritus, 
dermatalgia, hyperesthesia cutis, anesthesia cutis, and 
dystrophia cutis. Additions might be added to this 
group of such eruptions as erythema, urticaria, ec- 
zema, and others presenting nervous phenomena, 
but these are more properly and definitely arranged 
in other classes. 


I. Zoster. Synonyms: Herfes zoster ; Zona, Cin- 
gulum,; Shingles. Vhis is an acute inflammatory 
affection, characterized by the formation of groups 
of vesicles upon an inflamed and very sensitive sur- 
face corresponding to a definite nerve tract, accom- 
panied by more or less neuralgic suffering. Con- 
siderable pain may precede the eruption, and this - 
is very frequently supposed to be simple neuralgia ; 
counter-irritation, as by a mustard plaster, will be 
applied to relieve this, and the eruption will appear 
shortly after, quite independent, however, of the 
skin irritation. Zoster is peculiarly and essentially 

| 90 


NEUROTIC AFFECTIONS, QI 


a neurosis, as the eruption is found to be confined 
to the area of distribution of certain cutaneous 
nerves; and post-mortem examinations have dem- 
onstrated most conclusively, in many instances, dis- 
ease of the nerves supplied to the part. The nerve 
trunk is found reddened and inflamed, and the 
posterior or sensory ganglion is congested, softened, 
and succulent. 

The eruption of zoster is generally confined to 
one side of the body; on the chest (zoster pector- 
alis) or abdomen (zoster abdominalis), it will be 
found to reach in a band from the middle line pos- 
teriorly to the middle line anteriorly. The vesi- 
cles are usually in groups, and may run together, 
forming large bulle, but generally do not exceed 
the size of a small split pea.. They are quite pecu- 
liar, and different from those seen in any other af- 
fection, being flat, and having but slight tendency 
to rupture. The surface between them is reddened 
and often exquisitely painful to the touch, some- 
times presenting papules which have not yet devel- 
oped into vesicles. When the nerve lesion is seated 
in the lowest portion of the spinal axis, the eruption 
will occupy one or the other lower extremity (zoster 
femoralis). When the nerve inflammation is seated 
higher up, near the neck, the band of lesions will 
extend down the arm (zoster brachialis), and may 
even reach to the tips of some of the fingers. When 
still higher up in the cerebro-spinal axis, the erup- 


92 MANUAL OF DISEASES OF THE SKIN. 


tion will be seated on the head, extending behind 
the ear (zoster collaris), or upon the occiput ; occa- 
sionally the Gasserian ganglion is affected, and the 
eruption is distributed over one or more branches 
of the tri-facial nerve. The supra-orbital branch 
is most commonly affected, and the eruption then 
extends upon one side of the forehead, reaching 
into the hair (zoster ophthalmicus). Sometimes 
there are groups of vesicles upon the side of the 
nose or cheek; very rarely the inferior maxillary 
branch is involved, and the lesion is distributed 
over the chin. 

The peculiarity of the eruption of zoster, which 
is pathognomic, is that it is confined to one side or 
half of the body. Popular tradition says that if the 
eruption extend so as to reach around the entire 
trunk, the disease proves fatal: the reason for this 
superstition rests on the fact that ordinarily the 
eruption cannot thus extend because it occupies 
only well-defined nerve tracts, which extend only to 
the median line on either side. In very rare cases 
there is a simultaneous occurrence of zoster in two 
regions, and two distinct eruptions may sometimes 
be observed on the same side of the body, or on 
opposite sides; if by chance these should occur at 
the same level, the body might be encircled as has 
been observed a number of times. As a rule, 
herpes zoster occurs but once during life, but 
cases have been recorded where it has recurred, in 


NEUROTIC AFFECTIONS. 93 


one instance, as often as nine times in the same in- 
dividual. 

Ettology.—The immediate exciting cause of zoster 
is probably exposure to cold, but there seems to be 
some reason to believe that there is a deeper causa- 
tion, which at times renders the disease almost an 
epidemic. Certain it is that numbers of cases will 
often be observed in close succession or at the same 
time, and then a considerable interval may elapse 

before other cases are met with. As previously 
stated, the skin lesions are the direct result of nerve 
inflammation, involving the posterior or sensory root 
of the spinal nerves; they have also been observed 
as a result of injury of nerve trunks by disease or 
otherwise. 

Diagnosis—The markedly one-sided character of 
the eruption, the pain, the hyperzthesia of the re- 
gion, and the flat, grouped vesicles are quite suffi- 
cient to distinguish this from all other eruptions. 

Treatment.—Zoster is a self limited affection, 
the eruption tending to disappear within a week 
or two weeks. Treatment, however, may be of 
considerable benefit in shortening the duration of 
the eruption and lessening the distress from it. In- 
ternally, phosphide of zinc with nux vomica (For- 
mula 71) given as early as possible, and repeated 
every three hours, diminishes the pain and appears 
to shorten the attack. The internal use of the ci- 
trate of iron and quinia in large doses seems also to 


94 MANUAL OF DISEASES OF THE SKIN. 


be of service. Locally, the greatest relief is ob- 
tained by the application of a muslin band, thor- 
oughly dusted with starch, and sewed firmly around 
the affected portion of the body, the diseased sur- 
face being first dusted also with powdered starch. 
This muslin is applied to the part in such a manner 
as to make a tight covering over which the clothing 
plays, and is left untouched. until the eruption has 
disappeared. The comfort afforded by the protec- 
tion from friction which this gives is very great, and 
ordinarily no other local treatment will be required ; 
flexible collodion, containing a little morphine, 
painted over the part, also makes a comfortable 
dressing. Ifthe pain is sharp, considerable benefit 
may be experienced from the use of the galvanic 
current, the negative pole being applied with a 
moist electrode over the affected surface, and the 
positive on the spinal column; a mild current, from 
four to eight cells of a battery of ordinary strength, 
is all that is required. In some cases electricity will 
be required for a period after the disappearance of 
the eruption, to combat the excessive neuralgic pain 
which remains. 


2..Pruritus. Itching occurs as a symptom of 
many diseases of the skin, and may exist as an in- 
dependent affection either confined to definite areas, 
or affecting the entire surface. It is in the latter 
sense that the term pruritus is here employed, to in- 


NEUROTIC AFFECTIONS. 95 


dicate a functional disturbance in the sensory nerves, 
exhibited alone as itching, without any apparent 
changes in the skin except those caused by scratch- 
ing, or by the means employed to give relief. 

PRURITUS HIEMALIS.—This name is given to a 
form of itching of the skin which occurs principally 
in winter; generally beginning in the autumn, and 
increasing with the cold, it continues until the. ad- 
vent of warm weather. It may return year by year, 
and sometimes is the occasion of the severest suffer- 
ing, the pruritus being generally aggravated to- 
ward night. The chief places of itching are the ex- 
tensor aspects of the arms, the inner surfaces of the 
thighs, and the calves of the legs; in a case which 
has lasted some time, numerous scratch marks will 
beyseen: | 

PRURITUS SENILIS is the name given to the tend- 
ency to itch which exists upon the senile skin, and 
which is dependent in a measure upon the atrophy 
taking place in the structure of the skin in elderly 
persons. 

PRURITUS VULVA.—This will cause the patient 
to rub and scratch the parts violently in efforts for 
relief, without seeming to reach the seat of difficulty ; 
often, on examination, nothing will be seen but a 
chafed and dry surface, the result of rubbing. 

PRURITUS SCROTI and PRURITUS ANI may also 
occur unconnected with other diseases, and give 
very great distress, no skin lesions being presented. 


96 MANUAL OF DISEASES OF THE SKIN, 


While, however, itching occurs idiopathically in the 
region of the anus and genitals, it is more com- 
monly found to be only a sign of a moré or less 
slightly developed eczema, which may have existed 
unrecognized for years. 

Diagnosts—Considerable care should be exercised 
in differentiating pruritus as a disease from pruri- 
tus as a symptom: itching is a feature of very many 
diseases, and when lesions on the skin are seen, other 
than those caused by scratching, their real nature 
should be determined accurately ; itching may occur 
as a symptom of eczema, lichen, phthiriasis, prurigo, 
psortasts ?, scabies, seborrhea, syphilis ?, tinea crurts, 
(eczema marginatum), and uwrtecarza. Prurigo is re- 
cognized as a distinct, papular disease, entirely sep- 
arate from pruritus. 

L:tiology—No one cause can be assigned for pruri- 
tus; it is a functional affection due very frequently 
to other elements than those existing in the part it- 
self. Pruritus of the vulva is often associated with 
uterine disease, or with irritating vaginal secretions. 
Pruritus of the anus may arise from intestinal 
worms, and, together with pruritus of the scrotum, 
is often dependent upon oxaluria. The most careful 
investigation should therefore be made, and every 
possible means of correcting all aberrations from 
health employed. 

Treatment.—This must vary with the individual 
and the case. General itching is often benefited by 


NEUROTIC AFFECTIONS. 97 


mercurial cathartics (Formula 65), followed by nitric 
acid in full doses; quinine will be of much service 
when in malarial subjects. Gelsemium internally, as 
mentioned under eczema, gives relief, and chloral 
and bromide of potassium may be required to induce 
sleep. Diet seems to exercise some influence over 
pruritus, and all articles which “heat the system” 
will pretty certainly aggravate the sufferings of the 
patient. Alcoholic and fermented liquors, also 
spices and hot drinks all increase the itching for the 
time, and probably have more or less influence in 
prolonging the trouble; tea, when taken in excess, 
may act prejudicially. Harsh underclothing aids in 
keeping up the irritation, as also the excessive use 
of friction to the skin, as by flesh brushes ; in a 
number of instances I have observed that those suf- 
fering from general pruritus have previously in- 
dulged in Turkish baths to excess. 

Locally great comfort is experienced in all forms 
of pruritus from alkaline baths (Formule 1, 2, 3), 
followed by the application of carbolic acid in 
ointment (Formula 104). Sponging the surface with 
carbolic acid lotions with glycerine (Formula 44), or 
with the liquor picis alkalinus (Formula 42), diluted 
from ten to twenty times, also lotions with acetic 
acid and alcohol, give much relief. Electricity, both 
the direct and induced current, is often of great ser- 
vice. 

In pruritus of the vulva very many local applica- 


98 MANUAL OF DISEASES OF THE SKIN. 


tions will be found of more or less service, and 
again many may fail utterly. Vaginal injections 
with carbolic acid, half a drachm or more to the 
pint of tepid water, are frequently of great value; 
likewise lotions containing borax, morphia,. bella- 
dona, aconite, conium, and hydrocyanic acid (For- 
mulz 27, 32, 43). An ointment composed of cam- 
phor and chloral also gives’ relief in many instances, 
likewise ointments containing tar (Formule 105, 
106). 

Care must be exercised in attempting to relieve 
the itching not to excite inflammation of the skin; 
it not infrequently happens that stronger and 
stronger agents are employed, until an artificial 
eruption is excited which is both distressing and 
delays the proper treatment. Many of the measures 
of service in eczema are equally applicable in pru- 
ritus. 


3. Dermatalgia. Pain confined to the skin isa 
rare affection, but is occasionally met with. The 
_skin is generally sensitive to light pressure, but the 
positive neuralgic pain, which may last or may be 
quite transient, is sometimes relieved on deep, firm 
pressure; no visible signs of disease are noticed 
externally. Very little is known with regard to 
its causation, and little with regard to its treat- 
“ment. Like other neuralgias, it indicates a lowered 
nerve condition and calls for powerful nerve tonics 


NEUROTIC AFFECTIONS. 99 


and arsenic; locally, galvanism gives considerable 
relief. 


4. Hyperesthesia cutis. Excessive sensibility 
of the skin is a condition seen in hysterical and 
nervous patients, and is also an accompaniment of 
certain diseases of the brain and spinal cord. The 
patient complains of very considerable pain or dis- 
tress from even slight contact with the skin, of the 
air, bed clothes, etc. The condition is to be treated 
upon general principles. 


5. Anzsthesia cutis. Diminished or absent 
sensibility may exist in the skin, either generally or 
as a local manifestation. It commonly has connec- 
tion with internal causes, and is observed during 
the occurrence of leprosy, and also not unfrequently 
during the eruptive period of syphilis, as analgesia 
or loss of sensibility to pain; when it exists in 
syphilis a pin may be thrust through a fold of 
skin without causing pain. As a local manifestation 
it occurs as the result of injuries or diseases of cer- 
tain nerves or nerve centers. 


6. Dystrophia cutis. This term is employed to 
designate certain changes which occur upon the 
skin as trophic disturbances, due to disease or in- 
jury of certain nerve trunks. There have been quite 
a variety of lesions described as thus dependent, a 
number of them having been observed during our 
late war in connection with gunshot and other 


100 MANUAL OF DISEASES OF THE SKIN. 


wounds of nerves. The most commonly known 
form is the erythematous state or “glossy skin,” 
seen after injuries of nerves, whereby a part, as, 
one or more fingers, will become red, glossy, and 
shrunken at their ends, with an atrophic condition 
of the nails, as a result of injury of a nerve trunk in 
the arm. In certain: cases where the nerve injury 
has been severe and prolonged, vesicles have de- 
veloped, and in certain other instances distinct gan- 
erene of the skin has resulted from profound nerve 
injury. 

No particular line of treatment can be marked 
out for these cases, as this must be conducted on 
general principles, and little can, as a rule, be done 
to modify the skin lesions present. 


CHAPTER XI. 


CLASS IV. EXSUDATIONES.—EXUDATIVE OR IN- 
FLAMMATORY AFFECTIONS. 


THIS great class, which includes a large share of 
the diseases of the skin ordinarily met with, has 
two general subdivisions: (A) Those affections 
which are induced by contagion or infection; and 
(B), those of internal or local origin. Eleven differ- 
ent diseases are met with in the first, and twenty- 
four in the second group. 

The first group. embraces those which have gene- 
rally been known as the exanthemata, such as 
measles, scarlet fever, and small pox, together with 
certain others whose positions will be defined later. 
Some of these will be very briefly alluded to, inas- 
much as they belong more properly to general medi- 
cine than to dermatology; but they are all intro- 
duced here because they are at times of very great 
interest from a diagnostic point of view. Syphilis 
appears in this group for reasons which will be ex- 
plained later. 


1. Rubeola. Synonyms: JMeasles; Morbilh ,; 


Rougeole ; Masern. Measles isan acute, infectious dis- 
Io1I 


102 MANUAL OF DISEASES OF THE SKIN. 


ease, exhibiting inflammatory or febrile phenomena, 
accompanied by symptoms of mucous irritation, 
and the appearance upon the body of a maculo- 
papular eruption. The eruption of measles is of a 
mottled character, consisting of patches of a dull 
red or raspberry color, showing considerable ten- 
dency to assume crescentic shapes. 

In from one to two weeks after exposure there 
occur languor, back-ache, running from the nose, 
sneezing, and coughing, with congested eyes. After 
about four days of this, the eruption appears, first 
upon the forehead, then upon the cheeks and neck, 
and so on down, until by the end of the third or the 
fourth day it has covered the body, and is fading 
' from the hands. By the end of the fourth day of 
its completion, or the eighth day of its appearance, 
all traces are generally gone except a moderate 
scaling. 

Diagnosis.—The diagnosis of measles is usually 
not a difficult one, as the general and catarrhal 
symptoms point to its true character. In certain 
cases, however, it may resemble other eruptions, 
namely, scarlatina, roseola, rotheln (or German 
measles), and the erythematous syphilide, also possi- 
bly small pox, the eruption from copazba, and that 
from guznine, and finally certain cases of scattered 
erythema, and superficial erythematous eczema. The 
eruption which is sometimes called black measles 
is undoubtedly, in most if not all cases, hamor- 


INFLAMMATORY AFFECTIONS. 103 


rhagic small pox, under which name it will be de- 
scribed. 

Treatment.—The patient should be put to bed, and 
kept in a warm and even temperature until some 
time after the complete disappearance of the erup- 
tion. The diet should be light and unstimulating; 
broth, milk, and warm drinks should be given at 
first until the eruption is fading. Little or no inter- 
nal treatment is necessary, although it may be re- 
quired to meet complications. There is little doubt 
_ but that inunction, or greasing the surface, is of 
much benefit, both in measles and in scarlet fever, and 
should be generally practiced; it gives great com- 
fort to the patient, reduces the fever, and diminishes 
the danger of communicating the disease. It is 
very readily accomplished with cosmoline or with 
almond oil. A good method, common among many, 
is to soak a piece of fat bacon in water, in order to 
remove the salt, and then placing it in the oven, and 
allowing it to melt a little, to rub it well over the 
body. This may be repeated night and morning or 
oftener. 

2. Rotheln. Synonyms: German measles, Epi- 
demic roseola. YVhis name is applied to an acute, in- 
fectious disease, exhibiting hyperzmic, red blotches, 
often very closely resembling those of measles, but 
less sharply and clearly defined, without the ten- 
dency to assume the cresentic shape; the eruption 
is also more irregular in its course and development 


104. MANUAL OF DISEASES OF THE SKIN. 


than that of true measles, and is not accompanied 
by the coryza and the indications of mucous irrita- 
tion observed in the former, though it is often asso- 
ciated with some throat symptoms. There is but 
little constitutional disturbance, and patients are 
often up and around during its entire continuance. 
The rash more often resembles that of scarlatina 
than that of measles; it may be, however, of much 
shorter duration than either of these affections, and 
in light cases disappears within two or three days 
after its first manifestation. The eruption is liable 
to be confounded with the same as were mentioned 
in connection with measles. 

The prognosis is always favorable, and generally 
no treatment whatever is required. The disease is 
supposed to be moderately contagious; it certainly 
very frequently appears as a mild epidemic, and 
that more frequently during a time when measles 
or scarlatina are prevalent. 


3. Scarlatina. Scarlet fever is a far more seri- 
ous disease than either of the two preceding, and 
occasionally proves terribly fatal. The period of 
incubation is not definitely fixed, and may vary 
between one or two days and a week, or a little 
more; the sickness usually commences with more 
or less of a chill, often with vomiting, headache, 
sore throat, and general prostration. The eruption 
appears on the second day of the fever, first upon 


INFLAMMATORY AFFECTIONS. 105 


the face and then spreads rapidly down the chest 
and reaches the lower extremities on about the 
third day; shortly after this it is at its height, and 
by the fifth or sixth day begins to decline; by the 
ninth or tenth day desquamation is well established 
and proceeds for a week or more. The rash hasa 
peculiar scarlet color, whence the name of the dis- 
ease; in the beginning it is punctate, but when at 
all general it forms more or less of an evenly red- 
dened surface, hot and tense. The other symptoms 
always form a striking portion of the disease, and 
may prove very serious, the sore throat being a 
prominent and often dangerous feature. The 
tongue is coated in the middle, but red at the end, 
and covered with prominent papilla; the fever runs 
high, and the sufferings of the patient are generally 
very great. 

Diagnosis.—This is usually not very difficult if the 
entire history of the patient, and the character and 
course of the eruption, are taken into consideration. 
Certain cases may resemble measles, and the erup- 
tions mentioned in connection with that disease. 
There is also a punctate form of erythema which 
closely resembles the.eruption of scarlatina, but is 
unaccompanied by the constitutional symptoms; it 
is more uncertain in its distribution, and does not 
pursue the regular course followed by scarlatina, - 
but may desquamate and considerably resemble 
the rash of scarlatina in this respect; it is very 


106 MANUAL OF DISEASES OF THE SKIN. 


apt to appear most. markedly on the wrists and 
abdomen. 

Prognosis.—This is always doubtful. Cases vary 
ereatly in their severity; some are so moderate as 
to hardly seem to require the patient to take the 
bed, while others are fatal at the outset ; others still 
are fatal after a long continuance of the disease. 
After the eruption has entirely disappeared the 
dangers are by no means past, for the sequele of 
_this affection are among the most serious known. 
The kidneys are almost always affected to a greater 
or less degree, and if care be not taken the founda- 
tion of serious renal disease may then be laid; the 
dangers in this respect are peculiarly great during 
the period of desquamation. Other sequelz such | 
as ear disease, paralysis, etc., may also give great 
trouble. 

Lreatment.—The proper and complete treatment 
of scarlatina cannot be here discussed. Mention, 
however, may be made of the very great value of 
inunction practiced several times daily, as described 
under measles, both as a means of modifying the 
fever, giving comfort to the patient, and of protect- 
ing others from infection. The greatest care must 
be exercised to prevent the spread of the contagion 
of scarlatina; disinfection cannot be too complete, 
and the patient should be kept from mingling with 
others for at least a month after convalescence. 


INFLAMMATORY AFFECTIONS. 107 


4. Variola. Small-pox is an acute infectious dis- 
ease characterized by a pustular inflammation of 
both the cutaneous and mucous surfaces. The 
period of incubation varies very greatly, different 
writers placing. it at from six to twenty days. The 
patient then feels languor and lassitude, with shiv- 
ering, pains in the back, limbs, and head; there is 
often nausea and vomiting, constipation and general 
distress ; the pain in the back may be very great. 

After about two days of these symptoms small 
red points appear, first upon the forehead and — 
about the mouth, then upon the rest of the face; 
this soon proceeds to the neck and arms, then down 
the trunk to the lower extremities, and the entire 
body may be more or less affected by the end of 
twenty-four or forty-eight hours. These little 
points, which are diffused, small, and red, soon 
become conical and shotty; and by the next day a 
minute vesicular point may generally be observed 
upon them. Within the next two. days they en- 
large, become indented or umbilicated, and their 
contents, which are at first transparent, become 
whitish and milky. By the sixth or seventh day 
the contents appear as pus, and the vesicles become 
of a darker color and begin to show signs of drying, 
which-by the seventh or eighth day is quite appa- 
rent. As the eruption appears, the febrile symp- 
toms lessen and the patient may be comparatively 
comfortable when the eruption is in full vigor. By 


2 


108 MANUAL OF DISEASES OF THE SKIN. 


the eighth day the eruption has attained its height 
on the parts first affected, namely, about the face, 
and is less and less marked toward the toes. Thus 
many phases of the eruption are present at the same 
time. 

About the period when the eruption has at- 
tained its height, the secondary or suppurative 
fever occurs, and continues several days, until 
many of the pustules burst, or dry into scabs and 
crusts. The entire process of the formation and 
separation of the crusts may not be completed be- 
fore the twentieth day or even later. 

There are various forms or varieties of small pox 
mentioned, which it is not necessary to dwell partic- 
ularly upon. When the separate pustules occur 
thickly together, a large, extended surface may be 
involved in one mass of inflammation, and what is 
known as confluent small pox results. When small 
pox appears in those who have undergone vaccina- 
tion, it is generally in a greatly modified variety, 
and is hence named variola modificata or varioloid. 

In certain cases the disease assumes a terrific form 
known as variola maligna, or hemorrhagic small pox, 
which often passes under the name of dlack measles. 
Here the eruption does not exhibit the typical ap- 
pearance, but the surface may have a dark, purplish 
color from extensive capillary hemorrhages, and 
only the greatest care will demonstrate any papules 
or vesicles upon it. Thecourse and development of 


INFLAMMATORY AFFECTIONS. 109 


this form is varied ; but the disease generally proves 
fatal; the intensity of the poison seems to disinte- 
erate the blood, it exudes through the capillary ves- 
sels everywhere, and hemorrhages from the mucous 
membranes in all portions of the body occur, which 
are often frightful in character. The patient seldom 
survives the fifth day, generally dies by the third, 
and the eruption rarely displays any of its ordinary 
features. 

Diagnosts—When the disease is fully developed 
it is not difficult to recognize, but in mild, sporadic 
cases, and very early in its course, it may readily be 
mistaken for other eruptions. The papulo-pustular 
syphiloderm frequently resembles it very closely ; it 
is also occasionally quite difficult to distinguish be- 
tween mild cases of small pox and varicella; in the 
very earliest phases the eruption may resemble 
measles, scarlatina, acne, papular eczema, and some 
forms of erythema. 

Prognosis—The prognosis of small pox depends 
greatly upon the case, and no brief statement can 
be made with regard to it. In milder cases it is al- 
most invariably good, while more severe ones not 
infrequently prove fatal. | 

Treatment.—The measures to be employed also 
vary very greatly with the case. The disease being 
self-limited, no particular remedies are required to 
meet it, but the patient must be managed according 
to the indications occurring from time to time. 


TIO MANUAL OF DISEASES OF THE SKIN. 


The most important dermatological point in this 
connection is in regard to the possible prevention of 
the disigurements which so often result from the 
lesions, the much dreaded “ pitting” of small pox. 
Various methods and plans have been advocated 
from time to time for its prevention, all in the main 
having the same end in view. ‘The cause of the 
cicatrices which so frequently occur is undoubt- 
edly found in the ulcerations which result from 
disturbing the pustules during their normal course ; 
upon those parts of the body where they are not 
interfered with, the scarring is generally slight, if it 
occurs. at all, so that we can believe that if the pus- 
tules were left undisturbed they would oftener run 
their course without causing much if any destruction 
of skin tissue. The plan, therefore, which secures 
protection of the surface from friction and irritation, 
and which modifies the inflammatory action, is that 
best suited to accomplish thisend. For this purpose 
the eruption should be kept covered with some 
bland application of a mildly astringent character, 
calculated to soothe and diminish the congestion of 
-the surface. This is found in such applications as 
vaseline, or better still in a very weak zinc or cala- 
mine ointment (Formule 83, 84, 85) carefully spread 
upon the face. If there is itching there is no objec- 
tion to the addition of a little tar or carbolic acid to 
the ointment, as used for eczema. If greasy appli- 
cations are not agreeable a lotion may be used, as 


INFLAMMATORY AFFECTIONS. III 


that of calamine, or others which contain a protect- 
ive powder (Formule 25, 26), which may be allowed 
to dry upon the skin; a small amount of carbolic 
acid may be added to this if there is much itching. 
It is generally acceded that it is better to exclude 
the light; care must always be taken that the pa- 
tient does not pick or scratch off the crusts too soon, 
but allow them to take their full time for maturation 
and suppuration. The severe ectrotics which have 
been employed have not appeared to yield advan- 
tages commensurate with the pain and trouble at- 
tending their use, if indeed they have ever succeeded 
perfectly. 


5. Varicella. aricella or chicken pox is a mild, 
infectious disease, characterized by an eruption of 
small, isolated vesicles, often irregularly disposed, 
accompanied by a very moderate. constitutional dis- 
turbance. The period of incubation ranges between 
four and seventeen days, and the patient then com- 
plains of alittle fever and lassitude; but the consti- 
tutional symptoms are generally very insignificant, 
and frequently among the poor, children are brought 
to the out-patient clinics with varicella. Often the 
first sign of disease noted is the appearance of a few 
points, which are very quickly converted into small, 
quite distinct vesicles, which are remarkably trans- 
parent, and with but little surrounding inflamma- 
tion. 


II2 MANUAL OF DISEASES OF THE SKIN 


The vesicles, which are always of small size, gen- 
erally appear first upon the face, but frequently 
attention will be first called to their existence upon 
the back and chest. Their appearance here is gen- 
erally very conclusive, and the whole back should 
always be examined in making the diagnosis. The 
small spots of inflammation are seen to be oval in 
shape, directed across the body; the congestion is 
very superficial, easily disappearing on pressure, and 
the whole is surmounted by a minute, clear vesicle, 
which soon dries up into ascab. A peculiar feature 
of varicella is the successive eruption of the vesicles, 
which appear in crops, often a hundred or so new 
spots appearing each night for four or five days. 
There is usually a considerable amount of itching, 
and children, if not prevented, will not infrequently 
tear the surface, and often cause considerable scar- 
ring, which does not commonly take place where the 
eruption is undisturbed. The vesicles may come on 
any and all parts of the body, and I have seena per- 
manent scar left on the eyelid by a varicella vesicle. 

Diagnosis—The most common disease with which 
varicella is confounded is small pox in its milder 
forms; the regular progress of small pox from above 
downwards, compared with the irregular and succes- 
sive development of the elements of varicella; the 
superficial character, oblong shape, and quick vesi- 
cation of the latter, compared with the inflamma- 
tory papule of variola, proceeding to suppuration ; 


INFLAMMATORY AFFECTIONS. 113 


together with the general symptoms of small pox, 
should suffice to distinguish them. The only other 
lesions which could be mistaken for chicken pox are, 
an acutely developing papular syphiloderm, which 
sometimes vesicates, and a multiform erythema, 
which may at times present small or large vesicles. 

Prognosis —This is invariably good, unless the 
patient suffer from some great complication. 

Treatment.—The mildest laxative and diaphoretic 
treatment renders the patient more comfortable, 
but no remedies can alter the normal course of the 
disease. Some care should be exercised to prevent 
those with varicella from scratching the face, anda 
mild zinc ointment with a few drops of carbolic acid 
in the ounce (Formule 83, 84) will assist in allay- 
ing any irritation and preventing scarring. 


6. Vaccinia. This is an acute, infectious, vesicu- 
lar disease of the cow, which when communicated 
to man (usually in the process of vaccination) pro- 
tects from small pox. 

The process and results are familiar to all, and it 
does not come within the scope of the present writ- 
ing to enter on the subject, except from a derma- 
tological point of view. 

The accidents attending vaccination are numer- 
ous, but fortunately they very rarely occur, and in 
the vast majority of instances, the process pro- 
gresses normally, the sore heals, and little or no 


114 MANUAL OF DISEASES OF THE SKIN. 


sensible effect is produced upon the patient’s life or 
health. | 

VACCINAL SYPHILIS.—Groups of cases have been 
observed, and also very rarely separate instances, 
which demonstrate that the syphilitic virus has been 
and can be conveyed in the process of vaccination ; 
but compared to the numbers vaccinated, the cases of 
syphilitic inoculation are infinitely rare. The prog- 
ress of the disease is the same as when it is commu- 
nicated in any other manner, and the same phe- 
nomena may be manifested, unless interrupted by 
treatment, The vaccination sore may take fairly 
and exhibit sufficiently well the characters of vacci- 
nia. Within two weeks, however, the site of inser- 
tion of the virus hardens, and refuses to heal, and is 
transformed into a chaucre, which, unless properly 
treated, may last several weeks longer, and the evo- 
lution of constitutional syphilis follows, as described 
elsewhere. 

It is not yet absolutely determined in what 
method the syphilitic poison is conveyed; some 
have held that the vaccine lymph, if taken perfectly 
clear, cannot transmit syphilis. It is pretty certain 
that the intermingling of blood from a syphilitic in 
an active stage of the disease, renders the giving of 
syphilis probable; whether pus, epithelial débris, 
etc., as existing in crusts from vaccine vesicles, | 
could convey syphilis, is not yet decided. Safety 
lies in the use of good animal virus when possible, 


INFLAMMATORY AFFECTIONS. 115 


or in the securing of only perfectly clear lymph, 
from a healthy vaccinifer. The possibility of con- 
veying the disease by other means, as by a foul 
lancet, or soiled fingers, etc., must never be forgot- 
ten; it could also be conveyed from mucous patches, 
through the saliva, if used to moisten vaccine mat- 
ter, which improper practice is sometimes indulged 
in. 

VACCINAL ERYSIPELAS.—Sometimes in addition - 
to the very considerable amount of inflammation 
which may accompany vaccination, an erysipelatous 
action will take place, which may spread to very 
considerable extent, and prove a troublesome com- 
plication. Generally it remains confined to the 
arm, but in rare instances may extend to the body. 
This is far more apt to occur subsequent to the use 
of bovine virus than from perfectly healthy human- 
ized lymph. 5 

FURUNCULAR INFLAMMATION.—Besides a deep 
inflammatory action, which may result from harsh 
treatment of vaccination sores, it happens that in 
persons of a lymphatic temperament, or in those 
much run down, a furuncular state is developed, 
which may sometimes be the cause of very great 
trouble. At the seat of vaccination there may be 
deep seated inflammation, involving the cellular 
tissue, and ending in considerable scarring. In cer- 
tain rare cases the purulent infection seems to go 
further, and cutaneous abscesses occur elsewhere, 


116 MANUAL OF DISEASES OF THE SKIN. 


and this condition seems even to be communicable 
to others. 

Other than the above mentioned states, disease 
cannot be communicated by vaccination. Eczema 
may be excited in one predisposed thereto, or even 
psoriasis, but they cannot be communicated from 
one person to another by this means, nor is it proved 
that any disease except syphilis can be thus trans- 
térred, 

In regard to the vaccination of persons suffering 
from diseases of the skin, it may be stated that if 
carefully done, and if the sore is properly guarded 
afterwards, little if any harm can result: as a rule it 
is not well to vaccinate one suffering acutely from 
eczema, but in a sub-acute or chronic stage it may 
be successfully practiced without influencing the 
disease prejudicially. In those with irritable skins 
it is always well to employ the recently introduced 
vaccination shields to prevent undue violence being 
done to the pock. | 


CHAPTERS XIT. 


CLASS IV. EXSUDATIONES.—EXUDATIVE OR INFLAM- 
MATORY AFFECTIONS —( Continued ). 


7. Syphilis. Synonyms: fox; Lues. Syphilis 
is a chronic infectious disease, exhibiting a variety 
of inflammatory and neoplastic lesions which may 
affect every organ of the body, pursuing a more or > 
less definite course, and capable of transmission by 
inheritance; asa rule it can. be acquired but once 
during a life time. It is placed here among the dis- 
eases induced by infection or contagion, because as 
a disease it resembles those previously described, in 
its nature and also in many of its earlier lesions 
of the skin and mucous membranes; the later 
manifestations are to be looked upon as its se- 
quelz. 

Syphilis is one of the most important diseases 
which affects the human race, and the value of a 
quick recognition of its every phase, and a careful, 
proper, and thorough treatment cannot be overesti- 
mated. Syphilis occurs in an individual in only 
one of two ways, by inheritance or by contagion; 
and, although the exact mode and time of acquisi- 


tion is sometimes difficult to determine, there can 
117 


VTS MANUAL OF DISEASES OF THE SKIN. 


be no question but that the disease is always one 
and the same, transmitted in one way or the other, 
and never developed de novo. The subject of the 
acquired disease will be first considered, and inher- 
ited syphilis will be treated of subsequently. 

The primary lesion of syphilis, or point of entry 
of the virus into the system, is called a chancre, 
known also as an initial lesion; it is also spoken of 
as a hard sore, from the commonly observed, hard or 
parchment-like induration accompanying it, in dis- 
tinction from the soft sore or chancroid, which is 
a local affection, contagious, but not capable of in- 
fecting the system. The period at which the chancre 
makes its appearance after inoculation is uncertain, 
varying from ten to almost one hundred days; in 
contrast to this stands the chancroid which has an 
incubation of but a few days, or even hours. 

The initial lesion of syphilis may vary consider- 
ably in appearance, according to the location, health 
of the patient, amount and activity of the poison 
imbibed, etc.; in its earliest phases it is often diffi- 
cult of recognition. The points to be considered 
are, the occurrence of a sore, generally single, ten 
days or more after connection, its slow development, 
comparatively innocent appearance, and scanty and 
serous secretion, together with a painless induration 
of the lymphatic glands in one or both groins; these 
features will generally contrast strongly with the 
early appearance, rapid increase, and-rather abun- 


INFLAMMATORY AFFECTIONS. 119 


dant and purulent secretion from the result of 
chancroidal inoculation; this latter often exhibits 
multiple sores, angry in appearance, and is early 
accompanied by painful, general swelling about the 
inguinal glands of one side. 

By the end of a week induration can generally be 
made out in the chancre, and sometimes the indura- 
tion is first observed. The abrasion may often be 
very insignificant, and occasionally is hardly noticed 
by the patient. 

Chancres may affect any part of the body, and 
extra-genital chancres have been observed on almost 
every portion. While the most common mode of ac- 
quiring the disease is by impure contact, it is often 
communicated in ways which are quite innocent. 
Among the various methods by which the disease has 
been accidentally acquired, may be mentioned the 
processes of vaccination and circumcision, also that 
of tattooing and skin grafting; it has also been com- 
municated by a bite, and in the act of kissing, like- 
wise during nursing; and physicians, nurses, and 
midwives have acquired it in the discharge of their 
duty. The means of conveying the poison from 
one individual to another are almost as numerous as 
the objects of common life. It has been passed 
from one to another on the glass-blower’s pipe, also 
by means of smoking pipes and segars; surgical in- 
struments, lead pencils, tooth brushes, drinking and 
eating utensils, toys, etc., have all been reported as 


120 MANUAL OF DISEASES OF THE SKIN. 


the agents by means of which individuals have been 
infected. 

The important point to remember in connection 
with this is, that however or wherever the poison 
enters, the result is a chancre, the system is not af- 
fected in any gradual or occult manner, but invari- 
ably by the direct introduction of the poison at 
some particular place, and that at that place a sore 
results, which is the first stage of syphilis, the pri- 
mary lesion. 

The period at which the secondary lesions mani- 
fest themselves is somewhat uncertain. After the 
appearance of the chancre, a second interval of incu- 
bation occurs, during which the sore heals, and the 
patient may be in apparent health. But very soon 
symptoms of lassitude come on, often with consider- 
able headache and pains in the limbs, and shortly 
the entire surface is found to be covered with a con- 
gestive eruption, which may present one of several 
forms, macular, papular, or pustular. In conjunction 
with this eruption there is a general enlargement of 
the lymphatic glands, and more or less sore throat 
of a superficial form, and possibly iritis. The pa- 
tient is now ushered very completely into what is 
known as secondary syphilis. 

MACULAR SYPHILODERM.— Synonym: | Syphilo- 
derma erythematosum. This, the wrongly called 
syphilitic roseola, is the most common form, and 
occurs earliest after infection, often within the first or 


INFLAMMATORY AFFECTIONS. I2I 


second month, and occasionally entirely escapes the 
attention of the patient. It consists of a thickly set, 
slightly marked eruption of congestive blotches, of 
irregular shape and size, mostly small, seeming to 
be slightly elevated ; the color is of a pinkish red, 
giving to the skin a mottled look. In searching for 
it the abdomen and back should be examined, and 
the eruption becomes more.visible after a little ex- 
posure to the air. | 
Diagnosis—The diagnosis is quite easy when all 
points are considered; the eruptions with which 
it might be confounded are rubeola, roétheln, the 
eruptions produced by copazda and quinine, also pos- 
sibly some rare cases of erythema multiforme and 
urticaria, and the parasitic eruption ¢zxea versicolor. 
PAPULAR SYPHILODERM.— Synonyms: Syphilo- 
derma papulosum » Syphilitic lichen? WNarious forms 
of the papular eruption of syphilis are seen; some- 
times it follows directly upon the preceding, oftener 
it is that which is first observed. The entire body, 
head, and limbs may be the seat of a fine papular 
eruption, thickly set, with a moderate tendency to 
scale after some days’ duration. Or, the papules 
may be larger, and even of irregular size, some as 
large as a split pea, others the size of large pin 
heads. In other instances fine papules will be 
grouped around.a larger one, or the entire eruption 
of smaller or larger papules may be arranged more 
or less in circular or crescentic form. Still another 


122 MANUAL OF DISEASES OF THE SKIN. 


variety is seen in the large, flat papular syphilo- 
derm, whose elements may even reach the size of a 
large finger nail, and become more or less covered 
with a light, moderately adherent scale. The color 
of the papular eruption of syphilis is far more pro- 
nounced than that of the macular; and when it has 
lasted any length of time, it assumes a deep red, 
coppery tint; on disappearing coppery stains are 
left, but no scars. The papular eruption very com- 
' monly affects the palms and soles at the same time. 

Diagnosis — This eruption is more frequently con- 
founded with psorzaszs, it also resembles somewhat 
papular eczema, also lichen, lichen planus, and lichen 
scrofulosus. 

VESICULAR SYPHILODERM.—This is so rare that 
it is hardly worth considering; it seldom exists 
alone, and possesses no distinctive features. 

BULLOUS SYPHILODERM.— This is also.a very rare 
manifestation of syphilis, and in the acquired disease 
is only seen in broken down subjects. In hereditary 
syphilis it is not so uncommon, and is quite often 
met with on the palms and soles of infants, as will 
be mentioned later. . 

PUSTULAR SYPHILODERM.—Synonyms: Syphzlo- 
derma pustulosum, Syphilitic impetigo and ecthyma ? 
The pustular eruptions of syphilis are usually later 
than those just described; they may follow them 
either after or without treatment, or may seem to 
be the first manifestations of constitutional syph-. 


INFLAMMATORY AFFECTIONS. 123 


ilis. The pustules may be small and pointed, or 
flat, and generally crust over very soon; they are 
apt to remain some time, and when gone frequently 
leave small, depressed, brownish scars, which dis- 
appear slowly. The larger form of the pustular 
syphilide sometimes assumes a formidable appear- 
ance; the crusts may become large and heaped up, 
constituting what was formerly known as syphelitic 
rupia. This leaves considerable scarring, which is 
permanent. 

Diagnosts —TVhe pustular eruptions of syphilis may 
resemble pustular eczema, scabies, the eruption from 
fice, and that induced by zodide of potassium. 

TUBERCULAR SYPHILODERM.—Synonyms: Syph- 
tloderma tuberculosum , Tubercular syphilide , Sypht- 
fitic lupus ? The tubercular syphilitic eruption be- 
longs to the later stages of the disease, and is often 
spoken of as a tertiary lesion. It consists of one or 
many solid formations in the skin, generally about 
the size of a split-pea, roundish, and of a brown- 
ish red color. ‘They are seldom seen in great num- 
bers, and never over the whole surface; they are 
usually grouped together, generally forming circles 
or segments of circles. Occasionally the disease 
will travel over a large surface (serpiginous tubercu- 
lar syphilide). Ulceration takes place in the tuber- 
cles very readily, and they are often covered with 
crusts, though they may also only scale over and 
become absorbed without uleeration; the tubercu- 


124 MANUAL OF DISEASES OF THE SKIN. 


lar syphilide almost invariably leaves a permanent 
scar. 

Diagnosis.—This eruption of syphilis most resem- 
bles /upus, from which it is, however, to be carefully 
differentiated; the designation syphilitic lupus is 
wrong, lupus is a disease entirely distinct from 
syphilis. Certain cases may also resemble cpzthelioma 
and carcinoma, also the eruption of leprosy. 

GUMMY SYPHILODERM.— Synonyms: Syphzlo- 
derma gummatosum ; Syphilitic gumma,; Syphiloma ; 
Syphilitic lupus ? ‘This is one of the latest manifes- 
tations of the poison, and occurs principally in 
broken down subjects. It consists generally of a 
single mass of moderately firm substance, of vary- 
ing size, originating from the sub-cutaneous tissue, 
and sooner or later ulcerating through the skin. 
Beginning very small, it may remain for weeks 
without attracting much attention, but when it 
begins to ulcerate the destruction may be deep 
and extensive, attacking bones and joints... Gummy 
deposits of syphzloma may also form in internal or- 
gans, and may destroy life. 

Diagnosts—Cutaneous gummata may be mistaken 
in their early stages for fatty or fibrous tumors, 
enlarged lymphatic glands, and carcinoma, when 
ulcerating, they may resemble simple and varzcose 
ulcers, also lupus, and epithelioma. 

PIGMENTARY SYPHILODERM.—This is an altera- 
tion in the coloring of the skin, which is occasion- 


INFLAMMATORY AFFECTIONS. 125 


ally seen, mainly upon the neck and almost invari- 
ably in women; the reasons for these peculiarities 
in the eruption have never been explained. The 
skin appears of a darker color, a yellowish brown, 
and upon this are seen numerous white spots, sepa- 
rate or touching one another, as though a white 
sutface had been stained and then finger marks had 
been made upon it, showing the white beneath. 
This pigmentary lesion occurs during the first or 
second year of the disease, and is not the result of 
previous lesions ; it is quite different from the cop- 
pery brown stains left by many syphilitic eruptions. 

Diagnosis.—The pigmentation most resembles /ez- 
coderma , it isto be also differentiated from fznxea 
versicolor, and chloasma. 

MUCOUS PATCHES. — Synonyms: Condylomata ; 
Plaques muqueuses. These are moist lesions found 
upon mucous membranes or upon parts where two 
surfaces of skin come in contact and are softened 
and macerated, as about the anus and genital region, 
beneath the mammez, in the mouth, etc. ; they may 
occur at any period of syphilis, but are more com- 
mon during. the earlier stages. They differ some- 
what according to the situation: within the mouth 
they are superficial, of a grayish white color, with a 
raw appearance, oftenas though a coarse network had 
been stretched over a denuded surface. About the 
genitals they are more exuberant, of a reddish color 
and raised even to the height of a line above the sur- 


126 MANUAL OF DISEASES OF THE SKIN. 


rounding skin. The surface of mucous patches gives 
off a glairy secretion which is intensely contagious. 

Diagnosis—In the mouth these lesions are to be 
differentiated from szmple and aphthous stomatitzs, 
also from the white patches commonly seen in 
smokers, the /eucoplakia or wrongly called psorzaszs 
buccalis, and from eczema of the mucous membranes. 
In other locations, as about the anus and genital 
region, some care must be given to exclude the ordi- 
nary vegetations or venereal warts, which have no 
connection with syphilis. 

SYPHILIS OF THE PALMS AND SOLES.—Synonyms: 
Palmar and plantar syphiloderm: Syphilitic palmar 
psoriasis? Psoriasis syphilitica? During the early 
stages of syphilis, the palms and soles may be in- 
volved in the general eruption, which will here par- 
take of the ordinary characters, and need not be 
difficult of recognition. But later in the disease, 
even as long as twenty years after infection, these 
parts may be affected alone and give trouble in 
diagnosis. The lesions seen then are papules or 
tubercles, which are arranged in groups or circles, or 
parts of circles, and the surface is denuded of epider- 
mis over them, often causing painful fissures. 

Diagnosts.—-TYhe lesions in this situation may be 
mistaken for eczema and psoriasis: the latter should 
be excluded at once if well marked psoriasis is not 
found elsewhere, as it is probable that it never occurs 
on the hands without appearing on other parts at 


INFLAMMATORY AFFECTIONS. 127 


the same time. The diagnosis from eczema may at 
times be very difficult. It is to be remembered, 
however, that the lesion of syphilis is always com- 
posed of separate papules or tubercles, while the 
eruption of eczema spreads peripherally in an even 
surface; as a result, the margin of the syphilitic 
eruption will be sharply defined and scalloped or 
uneven, and the separate elements can always be 
made out; the eruption also is worse at the margin 
and with a tendency to clear in the center, exactly 
the reverse of what is seen in eczema. 


HEREDITARY SYPHILIS.—-When syphilis is in- 
herited, the child escapes the primary lesion, and the 
poison is in some way instilled into the system with 
life; a child born healthy may, of course, acquire 
syphilis while passing through the mother’s parts, or 
at any time afterwards, as by nursing an infected 
wet nurse, or otherwise; it then has zzfanzzle but not 
hereditary syphilis, and the disease begins with a 
chancre. 

The mode in which syphilis is communicated to 
the offspring has never been accurately determined ; 
it may be given directly from the father, although 
many have doubted it; the woman can readily com- 
municate the disease to her offspring, or rather, the 
child being part of the mother is necessarily affected. 
Syphilis is a very common cause of abortions, and, 
operating still further back, can cause sterility. 


128 MANUAL OF DISEASES OF THE SKIN, 


Inherited syphilis may manifest itself during 
intra-uterine life, and the child be born with an 
eruption, erythematous or bullous. Or, as is more 
commonly the case, the child comes into the world 
apparently healthy but soon fails in strength, and 
after about three or four weeks exhibits a weazened 
‘‘old man appearance,” has‘snuffles, and shortly the 
surface to a greater or less extent is seen to be cov- 
ered with a maculo-papular eruption, of a dusky red 
color. The mouth becomes sore from mucous 
patches, which also appear about the anus; the 
palms and feet often present bulla. When the 
eruption is plentiful the child often sinks and dies 
in spite of all treatment; if there is but a sparing 
amount it may improve rapidly under treatment, 
and regain apparent health. 

If the child survives and recovers from the erup- 
tion, it is still liable to the effects of the poison in 
the form of bone and eye disease, and even many 
years later may have tubercular and ulcerative 
lesions of the skin, and exhibit the peculiar teeth, 
the front upper incisors being pegged-shaped, 
notched from side to side, and thickened. 

As stated in the definition, syphilis may affect 
any or all of the organs of the body, and it may 
even destroy life: the limits and scope of the pres- 
ent work forbid entering more fully into the subject. 


Treatment.—While mercury may be rightly con- 


INFLAMMATORY AFFECTIONS. 129 


sidered an antidote for syphilis it is to be used with 
discretion, and often is efficacious only in propor- 
tion as all other measures are rightly employed with 
it. Hygiene is of the greatest importance in syphilis. 
Authorities are divided in regard to the. propriety 
of giving mercury for the primary sore, but no one 
who has seen much syphilis can deny that the in- 
duration melts away far more rapidly with than 
without mercury. For many reasons, however, it is 
advantageous to wait until the diagnosis is estab- 
lished with certainty, otherwise a non-syphilitic 
sore which healed while under mercury might be 
wrongly considered an initial lesion. There is little 
if any use of cauterizing the chancre lightly, as often 
practiced; if attempted at all it should be done 
‘very early and very thoroughly, as with fuming 
nitric acid; about the best local application is the 
black-wash (Formula 48), kept freely applied on lint, 
renewed several times daily; dry calomel is also a 
good application, and powdered iodoform is recom- 
mended by many, but its nauseous odor is a very 
great objection to its use. A valuable method is 
by means of the emplastrum mercuriale (Formula 
18), spread on linen and wound around the penis. 
In the earlier stages of syphilis iodide of potas- 
sium is of very little use, and mercury only need be 
given. This may be administered in a number of. 
ways, by the mouth and through the skin. Blue 
mass is largely used and should be given just short 


130 MANUAL OF DISEASES OF THE SKIN. 


of salivation, the teeth being slightly tender, the 
action on the bowels being checked by opium if 
necessary. Bi-chloride of mercury, in pill or solu- 
tion, so that from one-twentieth to one-eighth of a 
grain is taken, three times daily, is preferred by 
many, while others use the bi-cyanide in the same 
doses. The proto-iodide is one of the most valu- 
able preparations Cora 69), and was a favorite 
with Ricord. 

Through the skin there are three methods of in- 
troducing mercury; by inunction, by vapor baths, 
and by hypodermic injection. Inunction is usually 
performed with the unguentum hydrargyri U.S. P., 
rubbed alternately into the insides of the thighs 
and the sides of the chest, to the amount of 
from half a drachm to a drachm of the ointment 
once or twice in the twenty-four hours. The stain- 
ing from the “blue ointment’ may be obviated by 
employing the oleate of mercury, in twenty per cent. 
solution with an equal quantity of vaseline; the 
oleate is rather apt to irritate the skin. 

Mercury may also be introduced satisfactorily by 
means of mercurial vapor baths ; these may be given 
at public establishments, but are also readily admin- 
istered at home. The patient sits naked on a chair, 
beneath which is placed a lamp having a dish over 
it partly filled with boiling water, with a little cup 
on it containing half a drachm of calomel, or a 
drachm of the black oxide. A couple of blankets 


INFLAMMATORY AFFECTIONS. 131 


are thrown over the patient, and tucked in tightly 
over the chair, and the lamp lighted; the duration 
of the bath should be about half an hour, during 
which the patient should perspire freely ; the effect 
of the bath may be heightened by opening the 
blankets and inhaling a little of the mercurial fumes. 
It is well not to dry off the skin, but to get into bed 
either still enveloped with the blankets, or with a 
flannel night dress. | 

Hypodermic injections may be of service when 
rapid and sure effects are desired; the corrosive 
sublimate is generally used (Formula 108), and may 
be employed daily in doses of about one-eighth of a 
grain. 

In the later stages of syphilis, even six months 
after infection, the addition of iodide of potassium, 
forming what is known as the “mixed treatment” 
undoubtedly hastens the disappearance of the symp- 
toms, and contributes much to the patient’s well- 
being. To be most serviceable the mercury and 
iodide of potassium should be combined with iron 
and tonic remedies (Formule 61, 62), and thus com- 
bined-can be only of service. Syphilis being a dis- 
ease tending greatly to debility, a tonic treatment, 
both as to diet and hygiene as well as medicine, 
should be ever aimed at. 

Very late in the disease when gummy tumors 
exist, or when serious brain symptoms threaten, 
iodide of potassium may be required in much larger 


132 MANUAL OF DISEASES OF THE SKIN, 


doses, and should be pushed to almost any amount 
necessary to cause the symptoms to yield. When 
the iodide of potassium cannot be taken, that of 
sodium and ammonium may be used, or iodine given 
in the compound tincture of iodine, or as iodoform, 
or the iodide of starch (Formula 75) may be em- 
ployed. But it is never to be forgotten that a little 
mercury may be required | even very late in the his- 
tory of syphilis. 

In regard to internal treatment a few general di- 
rections may be of service. Mercury if properly 
used does not do harm, but good, and all the popu- 
lar fears about the drug remaining in the system 
and causing subsequent trouble, are wholly ground- 
less; when used as directed, and for syphilis, it is 
surely a tonic. It is never necessary really to sali- 
vate, and although this accident sometimes hap- 
pens, it should be sedulously guarded against. To 
this end the mouth and teeth should be kept clean, 
and the state of the gums watched; the slightest 
tenderness of the teeth on biting should excite sus- 
picion. The mercury should then be lessened or 
stopped, and chlorate or permanganate of potassa 
be used freely as a gargle, and, if necessary, bella- 
donna or atropine given internally. 

The treatment of syphilis should be continued 
long after the disappearance of all symptoms; best 
authorities place the entire duration at two years, 
at the least. 


INFLAMMATORY AFFECTIONS. 133 


Infantile and hereditary syphilis is best treated 
by means of inunctions, with mercurial ointment 
diluted once or more, rubbed in and worn on the 
binder; tonic treatment should also be used as re- 
quired. Gray powder also answers well, and I have 
seen excellent results even in small infants from the 
“mixed treatment” (Formula 62). Later lesions 
of the bones do very well on the syrup of the 
iodide of iron. 

Little need be saidvin regard: to the-local treat 
ment of the eruptions of syphilis. Generally none 
is called for; if any be required, it is generally such 
as would be indicated by a similar lesion not due to 
syphilis. For obstinate tubercular eruptions the em- 
plastrum hydrargyri (Formule 18, 19) is of service; 
scaly eruptions on the hands are much benefited 
by the application of the oleate of mercury in five 
or ten per cent. solution. Calomel in ointment, half 
a drachm or a drachm to the ounce, is often valua- 
ble, or ammoniated mercury (Formula 91); and 
where there is much pain and unhealthy discharge 
from ulcerating gummata, powdered iodoform alone 
or in ointment, fifteen to forty grains to the ounce, 
is of service; its pungent odor is a great objection to 
its use in private practice. A compound ointment of 
mercury, iodine and lead (Formula 103), is valuable 
in old palmar syphilis, and even in syphilitic tumors. 


8. Pustula maligna. Malignant pustule is the 


134 MANUAL OF DISEASES OF THE SKIN. 


result of inoculation of the poison from animals 
with charbon: inoculation takes place through 
abraded surfaces. After a very brief incubation a 
small, dark red induration occurs, which soon vesi- 
cates, and rapidly becomes a pustule, followed by a 
slough. The sore becomes gangrenous, severe con- 
stitutional symptoms appear, and death may result 
in a few days. ~ | 

The treatment consists in the destruction of the 
inflamed point with powerful escharotics at the ear- 
liest possible moment; the separation of the slough 
is to be encouraged by charcoal poultices, and at- 
tention is given to sustaining the life powers of the 
patient. 


9. Equinia. Glanders is a rare affection which 
originates from contagion derived from a similar 
disease in the horse. In this animal it is character- 
ized by inflammation of the nasal cavity, leading to 
swelling and ulceration, with a purulent discharge; 
later the lymphatics become involved, and swellings 
may appear in various parts, which ulcerate and dis- 
charge fetid matter. 

In man there is first inflammation about the 
wound or scratch where the poison gained entrance, 
and lymphatic inflammation accompanied with pros- 
tration and rheumatic pains; soon the nasal cavity 
is inflamed and a bloody purulent secretion oc- 
curs; very shortly a more or less general pustular 


, 


INFLAMMATORY AFFECTIONS. 138 


eruption appears, first on the face, somewhat re- 
sembling small pox, but in reality being more tuber- 
cular, and with a subsequent vesiculation or pustu- 
lation, and with a rapid tendency to ulceration. 

The prognosis is almost always bad, the disease 
frequently proving fatal in about a week. 

There is no treatment established other than such 
as is indicated by the conditions present. /arcy ap- 
pears to be identical in nature with glanders, but a 
somewhat different manifestation. 


10. Diphtheritis cutis. Under certain circum- 
stances the skin may become the seat of diphtheritic 
membrane, wherever there has been any abrasion ; 
even eczematous surfaces are said to become thus 
covered. In very rare instances it is stated that a 
vesicular eruption occurs in the disease, and, the 
vesicles taking on the membranous formation, may 
coalesce, and large surfaces of disease be thus formed. 


11. Erysipelas. This is an inflammatory disease of 
the skin, more commonly of the head and face, at- 
tended with fever of greater or lesser severity, gen- 
erally commencing with a chill, and accompanied 
with considerable prostration. The skin appears 
swollen, red, and shiny, and burns and is tender to 
the touch; the eruption may spread very rapidly 
until a large portion is involved. In certain cases 
the disease travels over much of the surface of the 


136 MANUAL OF DISEASES OF THE SKIN. 


body, disappearing in one portion as it moves on; 
thus the process may be repeated several times. 
This is called erysipelas migrans, wandering or mi- 
gratory erysipelas. 

The real cause of erysipelas, the poison, is as yet 
unknown ; the disease appears most certainly to be 
transmissible by contagion, also through the air, as 
when surgical wards of a hospital become infected, 
so that every wound is attacked by the disease. 
But there seem also to be other cases where the dis- 
ease starts idiopathically, without connection with 
any previous case. 

There are again a certain number of instances 
where an erysipelatous eruption appears again and 
again on the face, generally on one side, creeping 
over the nose, so as to cover the middle portion of 
the face in a few days; there is some malaise and 
fever, but the condition is rarely very severe. These 
cases are generally observed to be associated with 
nasal catarrh, and the process seems to be excited 
by lymphatic absorption from ulceration within the 
nasal cavity: these I have looked upon as a pseudo- 
erysipelas, and non-contagious. 

Diagnosis.—Erysipelas should not be confounded 
with any other eruption, when the constitutional 
symptoms and the character of the lesions as de- 
scribed are taken into consideration. But many cases 
of erythematous eczema, especially on the face and 
legs, are often wrongly called “ chronic erysipelas,” 


¢ 


\ 


INFLAMMATORY AFFECTIONS. 137 


as also cases of acne rosacea. fTerpes zoster was also 
formerly confounded with erysipelas, which accounts 
for some of the varieties described in older books, as 
vesicular and bullous erysipelas: while the inflam- 
mation may occasionally result in an indefinite rais- 
ing of the epidermis by fluid, this is really very rare. 
Lrythema is differentiated by the absence of consti- 
tutional symptoms, by its more superficial character 
and more rapid course, and by the ABH of desqua- 
mation later. 

Treatment.—A sharp purge with compound ca- 
thartic pills, followed by very free and oft repeated 
doses of the tincture of iron, together with thorough 
powdering of the surface with flour will very com- 
monly be all that is required. 


CHAPTER AIT 


CLASS IV. EXSUDATIONES.—EXUDATIVE OR _IN- 
FLAMMATORY AFFECTIONS.—(Contznued.) 


Group B.—Of Internal or Local Origin. 


THIS group contains many of the most common 
and troublesome diseases of the skin, indeed two- 
thirds of the cases ordinarily presented would be 
rightly classed here. No attempt at etiology is made 
in their arrangement, which is based upon the gross 
lesional aspects belonging to each affection. The 
nine sub-groups correspond largely to those of Wil- 
lan. Some of the eruptions here placed are of local 
origin; most of them are from internal causes, many 
of which are as yet undetermined. 


I, ERYTHEMATOUS ERUPTIONS. 


Three diseases are found here, voseola, erythema, 
and urticaria, all characterized by a very superficial, 
congestive or slightly inflammatory redness, disap- 
pearing momentarily on pressure. 


1. Roseola. This is the most superficial of cuta- 
neous inflammations, presenting often only a transi- 


tory redness, hardly more than a hyperzmia, al- 
138 7 


INFLAMMATORY AFFECTIONS. 139 


though in some cases the lesions may last several 
days. The term has been variously applied by 
writers, both to idiopathic rashes, and to those symp- 
tomatic of, or belonging to other affections; thus 
we hear of voseola vartolosa, roseola vaccinia, roseola 
cholerica, roseola syphilitica, etc., referring to fugi- 
tive congestive eruptions seen in small pox, vaccinia, 
cholera, syphilis, and other diseases. 

The term roseola is here used to represent an 
idiopathic eruption of rose-colored papules or small 
patches, diffused more or less completely over the 
whole surface and not connected with any other 
disease state. There is generally slight constitu- 
tional disturbance, restlessness, and fever. The 
causes are temporary digestive disorders; it is most 
commonly seen in infants. The older designations 
of Willan, voseola estiva, autumnalis, annulata, in- 
fanttlis, etc., are quite unnecessary. 

Diagnosis—This must be made from scarlatina, 
measles, ritheln, the erythematous syphilide, and the 
eruptions caused by the internal administration of 
coparba, quinine, belladonna, etc. 

Treatment.—Little or nothing is required beyond 
slight ‘attention to the digestion and action of the 
bowels: the condition is very fugitive. 


2. Erythema. Three varieties of erythema are 
recognized in the classification, erythema simplex, 
é. multiforme, and e. nodosum. 


140 MANUAL OF DISEASES OF THE SKIN. 


ERYTHEMA SIMPLEX.—This is characterized by 
the presence of a patch or patches of evenly reddened 
surface, an inch or more in diameter, of various 
shapes, a little raised, slightly hot to the touch, and 
disappearing momentarily on pressure. The con- 
dition is often a transitory affair, lasting a single 
day ; sometimes the patches remain longer or recur 
repeatedly. 

ERYTHEMA MULTIFORME.—Polymorphous ery- 
thema is avery curious and often puzzling affection. 
It includes several conditions, namely: erythema 
palpulatum, e. tuberculatum, e. annulare or margina- 
tum, and e. vesiculosum or é. tris: that is, while the 
real lesion is spoken of as an erythema, the process 
may be so severe that papules or raised rings are 
formed, and the congestion may even be so great 
that fluid exudes and vesicles or bullae form. With 
all of these, larger erythematous patches of various 
shapes are often observed, quite appreciably raised, 
hot to the touch, and attended with burning sensa- 
tions. The hands and forearms are almost always 
most severely affected, also the backs of the feet and 
the thighs, the eruption being commonly symmetri- 
cal; the face is usually involved. There is generally 
some malaise and more or less of fever. The dis- 
ease may be prolonged several weeks, with repeated 
accessions of lesions. 

ERYTHEMA NODOSUM.—Synonyms: Dermatitis 
contusiformis. ‘This is often described as a separate 


INFLAMMATORY AFFECTIONS. IAI 


disease, distinct from the preceding forms of erythe- 
ma; but, while it generally presents quite charac- 
teristic features of its own, it is also seen in less 
marked degrees, and in forms which so resemble the 
multiform eruption previously described, that there 
can be little doubt as to their relationship. 

When characteristically developed, the eruption 
is in the form of rounded, more or less elevated, 
node-like blotches, which are reddish at first, but 
with a tendency soon to become darker colored and 
to fade to a yellowish hue as they disappear, within 
a week or so of their development. They are far 
more commonly developed on the extensor aspects 
of the limbs, but may appear elsewhere: they are 
accompanied with burning pain and are tender on 
pressure ; unless injured they never suppurate, and 
the affection is usually a mild one, although it may 
be prolonged by successive crops of eruption. 

Diagnosis.—Erythema simplex may be mistaken 
for erystpelas and erythematous eczema, Erythema 
multiforme at times resembles urticaria, papular ec- 
gema, and lichen planus, while the gyrate forms may 
be mistaken for ringworm. Erythema nodosum 
may be confounded with druzses and cutaneous ab- 
scesses, and, when occurring only over the tibiz, the 
swellings resemble syphzlitic nodes. | 

Treatment.—Very little medication is called for 
in any of the forms of erythema, except when the 
multiform variety is due to nervous depression, 


142 MANUAL OF DISEASES OF THE SKIN. 


in which case the most careful treatment will be re- 
quired. Ordinarily a little stomach and bowel de- 
rangement will be discovered, and rhubarb and soda 
(Formula 55) will generally correct this; when more 
severe, such a mixture as that of magnesia and iron 
(Formula 52) will be found serviceable. Locally 
protective powders (Formule 76, 77, 78, 79), or as- 
tringent lotions (Formule 25, 26), assist in allaying 
the cutaneous hyperzmia. 


3. Urticaria. Synonyms: JWVettle rash, Hives; Cnt- 
dosis; Febris urticata; German, Nesselsucht , French, 
Urticatre. This is characterized by the sudden ap- 
pearance of flat, solid, slightly elevated blotches 
called wheals, which are irregular in size and shape, 
and are either reddish or paler than the normal 
skin. The eruption is always accompanied by irri- 
tation of a pricking, stinging, or burning character, 
which is often worst just before its appearance. 
The individual spots generally last but a short time, 
from a few hours to a day, and the eruption may be 
acute and consist of one or a few outbursts, or it 
may be chronic with the continual or frequent re- 
production of the wheals. The spots may vanish 
as suddenly as they appear, or may subside slowly. 
One variety, to be described, leaves a small, solid, 
papule in its center. There is usually stomach or 
bowel disturbance, a coated tongue, and, if the at- 
tack be sudden, a little headache and even fever. 


INFLAMMATORY AFFECTIONS. 143 


Several forms of urticaria are spoken of. 

ACUTE URTICARIA.—This generally arises from 
acute gastric disturbance, often from irritating in- 
gesta, as stale fish, fruit, etc. There is a general 
sense of fullness, the entire skin seems hot and 
tense, and shortly a greater or less development of 
wheals takes place, accompanied by most distress- 
ing burning and itching. 

CHRONIC URTICARIA.—This form is often devel- 
oped insidiously; the patient may seem to enjoy | 
good health, but is tormented with the continual 
formation of wheals and irritation of the skin, which 
is generally greatest after meals. In certain cases 
the urticarial attack will come on at a regular time 
of day, or even on alternate days, and is found to de- 
pend upon malaria, and to be broken up by efficient 
doses of quinine. 

URTICARIA PAPULOSA.— This is sometimes 
wrongly called “chen urticatus, because of the 
lichenoid papules which are left after the subsi- 
dence of the wheals. It is most commonly seen in 
children, and often the only visible eruption will’ 
be scratched papules with a faint halo around them. 

URTICARIA TUBEROSA.—Occasionally the swell- 
ings of urticaria assume some size, even to almost 
that of half an egg; this has been called gzant urtz- 
carta, of which I have seen one striking case. When 
the urticarial swelling takes place about the face 
considerable deformity may be produced; some- 


» 


144 MANUAL OF DISEASES OF THE SKIN. 


times the tongue is affected, and the patient may 
be almost choked. ; 

URTICARIA PIGMENTOSA.—A very curious con- 
dition has been described under this name to which 
Tilbury Fox once gave the name of xranthelasmoidca, 
because of the resemblance of the patches which 
are left by it to the yellow patches of xanthelasma. 
It isarare affection, of which I have seen but two 
cases in this country and several in England. The 
earlier development is in the form of wheals like 
ordinary urticaria, which on subsiding leave yellow- 
ish, slightly elevated patches, which remain for a 
long time; the cases have been mostly in very young 
children, and have given rise to much suffering. 

Diagnosis.—Ordinarily urticaria is easily recog- 
nized by the history, and the presence of the 
wheals; it may be mistaken for erythema multt- 
forme, and the papular variety often resembles sca- 
bes, and also papular eczema. 

Prognosis.—An acute attack, as from mushrooms, 
stale fish, etc., occurring for the first time, may pass 
off readily, or it may be the beginning of a chronic 
condition: the chronic form often proves most re- 
bellious: 

Treatment.—Where an irritating substance may 
reasonably be supposed to be yet in the stomach, 
an emetic should be given; almost always a moder- 
ate purgative is of service at the beginning of treat- 
ment, as calomel and jalap, or blue mass (Formula 


INFLAMMATORY AFFECTIONS. 145 


65), and the laxative effect may be kept up by mod- 
erate use of rhubarb and soda, or magnesia (Formula 
55). In more chronic cases the greatest care must 
be paid to the diet and hygiene, and every possible 
source of ill health removed. Especially must the 
excretion from the bowels and kidneys be cared 
for; aloes and iron (Formula 66) aids the former 
excellently, and alkaline remedies (Formule 53, 54, 
55) are generally called for; in chronic cases min- 
eral acids are of most service. 

The local treatment is of considerable impor- 
tance; first, all irritating elements must be removed, 
as flannel next the skin. Alkaline baths (Formule 
I, 2, 3) are of great value, with the subsequent ap- 
plication of carbolized ointments (Formula 104); 
when there is much liver disturbance acid baths 
are of most value (Formula 5); salt water baths are 
also good. Ammonia spirits relieves the itching, 
also lotions with acetic acid, and alcohol, also bella- 
donna, aconite, and carbolic acid (Formule 32, 44). 
On exposed parts much relief may be obtained by 
calamine and zinc lotions (Formule 25, 26), and 
chloral and camphor in powder or ointment (For- 
mulze 81, 105) assist Seay 


II. PAPULAR ERUPTIONS. 


There are two distinct eruptions whose charac- 
teristic lesion is recognized to be a papule, namely, 
lichen and prurigo. 

7 


146 MANUAL OF DISEA'SES OF THE SKIN. 


4. Lichen. Lichen is characterized by the pres- 
ence of inflammatory papules, of various sizes and 
shapes, though generally small, which preserve their 
character to the end, and are accompanied by 
marked itching. The name lichen has been vari- 
ously used and abused, but at present is applied 
with tolerable unanimity to three or perhaps four 
conditions which resemble each other, if indeed they 
are not closely related; these eruptions differ so 
much that their separate consideration is necessary. 

LICHEN SIMPLEX.—In this the papules are pointed 
and hard, with a redness which disappears momen- 
tarily on pressure; they may be scattered, or gath- 
ered together in groups, and generally affect the 
extensor surfaces of the limbs, and also the body. 
The eruption may very readily be confounded with 
papular eczema. When grouped together the term 
lichen circumscriptus has been used. Lichen tropicus 
or prickly heat, consists of numerous, minute, bright 
red papules, seen commonly in infants; by some 
writers it has been regarded as a congestive affec- 
tion of the sweat glands; it is a transitory affair, 
and requires little treatment. Lichen agrius is an 
old term for aggravated lichen, and the cases to 
which this name was given are now generally recog- 
nized as eczema. Lichen urticatus is another name 
given to urticaria papulosa. 

LICHEN RUBER PLANUS.—The papules in this are 
sharply defined, about a line in diameter, flat on the 


INFLAMMATORY AFFECTIONS. 147 


top, and often slightly depressed in the centre, 
of a purplish pink color, and shiny on the surface. 
They appear quickly and increase to the size men- 
tioned, and will often remain for a very considera- 
ble time, resisting treatment; they may run to- 
gether, forming patches of some size. They more 
commonly appear first on the wrists and backs of 
the hands, and the glans penis may be first affected. 
There is sometimes great itching, often it is slight. 
The lichen ruber of Hebra is thought to be the 
same affection; the papules here are more acumin- 
ate, and tend to crowd together ; it is very rare in 
this country. 

LICHEN SCROFULOSUS.—This is in reality lichen 
simplex occurring in strumous subjects. It is char- 
acterized by reddish or yellowish papules, more or 
less grouped, and usually covered with greasy scales; 
the skin is commonly inactive and dry; there is 
little itching. The eruption is rare in this country, 
but has been observed here. 

Lichen pilaris is not a true lichen, but an epi- 
dermal hypertrophy, and will be described as hera- 
tosis pilaris. 

Diagnosis —All the forms of lichen may be mis- 
taken for papular eczema, and urticaria papulosa, also 
for the scattered papular syphiloderm; great care 
will often be necessary in differentiating the erup- 
tion from scadzes. Lichen planus sometimes resem- 
bles guttate psoriasis and erythema papulatum. 


148 MANUAL OF DISEASES OF THE SKIN. 


Prognosis. —Acute lichen generally yields readily, 
as also lichen scrofulosus; lichen planus often proves 
obstinate. , 

Treatment.—The treatment of lichen is essentially 
that of eczema, and need not be fully detailed. 
Both internal and external measures are required; 
alkaline tonics and baths are especially valuable. 


5. Prurigo. The distinction must be clearly 
made between pruritus and prurigo ,; the former isa 
subjective symptom, namely itching, which accom- 
panies many eruptions, such as eczema and scabies, 
and which may also occur idiopathically, and thus 
constitute a disease, as already described. Prurigo 
represents a papular eruption of peculiar character, 
accompanied also by itching, which is usually in- 
tense. The name prurigo has been very vaguely 
applied, and many older writers thus designate the 
eruption caused by lice, which is now known as 
phthiriasis or pediculosis. The terms prurigo po- 
dicts and prurigo scroti are also met with, used to 
designate an itching eruption of the anus and gen- 
ital region; most of these cases are eczema, others 
simply pruritus; prurigo does not affect these por- 
tions alone. Again, others have applied the term 
‘prurigo to papular urticaria, known also as lichen 
urticatus, already described; and others speak of 
prurigo senilis, to indicate the pruritus which at- 
tends the changes in the skin incident to old age. 


INFLAMMATORY AFFECTIONS. 149 


As understood by dermatologists to-day, prurigo 
is characterized by the development of numerous, 
small, solid papules deep in the skin, either of the 
color of the integument or of a pale red, and at- 
tended with great itching. The papules are the 
primary lesions, and until torn in scratching exhibit 
little or no inflammatory element ; when recent, they 
are felt rather than seen, although they project 
slightly above the surface. The original seat of 
their appearance is the extensor surfaces of the 
limbs; as later features we have their more or less 
general development, with harshness and pigmenta- 
tion of the skin, enlarged lymphatic glands in the 
groins, and exhaustion from constant irritation. 

Diagnosis —This eruption in a severe form, such 
as is seen in Vienna, is a very rare one in this coun- 
try, although cases of papular eczema and urticaria 
often simulate it very closely. But in a milder form 
it is not unfrequently met with among the poor, 
especially in children ; here a large portion of the sur- 
face is moderately covered with an eruption, papular 
in character, with many scratched points, and a dry, 
hard surface; true prurigo is said always to begin 
in childhood. It resembles very closely urticaria 
papulosa, but papules occur without the existence 
of wheals; it also resembles scadzes. This milder 
form in children corresponds to what has been de- 
scribed by the French as strophulus prurigineux. 

Prognosis—Always very doubtful. 


150 MANUAL OF DISEASES OF THE SKIN. 


Treatment.—This relates largely to general mea- 
sures, looking towards a perfect restoration to 
health, which is always lowered in these patients. 
Kidney and bowel secretion should be attended to, 
and iron, cod-liver oil, the phosphates, etc., are 
given. Arsenic has only a moderate effect, but car- 
bolic acid internally has been said to control the 
itching in a measure. Local treatment is very im- 
portant; alkaline baths (Formule 1, 2, 3,4), followed 
by a carbolized ointment (Formula 104), are of value. 
Also tarry preparations, as the alkaline tar solu- 
tion (Formula 42), diluted to a strength sufficient to 
give relief; likewise oil of cade freely applied, pure 
or diluted, with cod-liver or linseed oil (Formula 41). 


III. VESICULAR ERUPTION. 


But one name appears here, namely herpes, al- 
though vesicles are observed in several other dis- 
eases, because in this alone the vesicle is a constant 
pathognomonic sign. This herpes is distinct from 
herpes zoster or zona, which has already been de- 
scribed as a neurosis because of the constant path- 
ological nerve change found in it. 


Herpes. Herpes is an acute inflammatory affec- 
tion, whose characteristic lesion is a group or groups 
of flattened vesicles, seated on an inflamed and sen- 
sitive base. Four varieties are recognized: herpes 
Sebrilis, k. tris, h. progenitalis, and h. gestationts. 


INFLAMMATORY AFFECTIONS. I51 


HERPES FEBRILIS.—Synonyms: Herpes facialis ; 
flerpes labialis. ‘This relates to what are commonly 
known as “cold sores ”’ or “ fever blisters,” occurring 
most frequently about the mouth and lips; the erup- 
tion is also occasionally seen elsewhere on the face, 
and inside the mouth, and even about the anus. The 
phenomena of burning and a little pain are familiar 
to all; very little is known of their significance. In 
certain rare cases a general eruption of febrile 
herpes has been observed, (herpes généralisé febrile), 
attended with considerable malaise, headache and 
fever. 

HERPES IRIS.—Synonyms: Herpes circinatus ; Hy- 
droa? ‘This is a comparatively rare eruption, and is 
closely allied to erythema multiforme, if indeed it is 
not to be looked upon as a phase of it. The erup- 
tion is characterized by the occurrence of vesicles 
in circles around a central one; sometimes several 
develop in succession and a series of concentric 
rings of vesicles may be observed. These cases have 
sometimes been described as herpes circinatus,a term 
more commonly applied to ringworm, or tinea tri- 
chophytina. 

HERPES PROGENITALIS.—Synonym: FHlerpes pre- 
putialis. In this the small groups of flat vesicles 
form and rupture very quickly, so that there is 
usually presented only a raw surface, which may 
readily be mistaken for venereal lesions. The erup- 
tion is most apt to appear on the prepuce, but may 


152 MANUAL OF DISEASES OF THE SKIN. 


also come on the glans and body of the penis, also 
onthe female labia. The superficial and grouped 
character of the vesicles, abrasions, or ulcerations, 
and their sudden appearance after a little burning 
pain, should distinguish them. Their course is 
short, and in a few days, if uninjured, they crust 
over and disappear. 

HERPES GESTATIONIS.—This curious eruption, as 
the name implies, belongs to the pregnant state. 
During the later months of gestation, generally after 
the seventh, sometimes beginning with the fifth 
month, excessive itching begins upon the extremi- 
ties, and is soon followed by the development of 
grouped papules which soon vesicate.and may de- 
velop into bullz of some size. The eruption is pro- 
longed by successive crops, and lasts until delivery, 
when it disappears suddenly, or may be followed by 
an outburst three days or so after parturition. 

Diagnosis —This should not be difficult. Febrile 
herpes may resemble mucous patches; herpes iris 
could only be mistaken for multiform erythema; the 
herpetic eruption on the genital regions resembles 
venereal sores and also balanitis ; and herpes gesta- 
tionis appears like papulo-vesicular eczema. 

Prognosis —Al\\ forms of herpes tend to spontan- 
eous recovery; but herpes progenitalis is very apt to 
relapse, and is important as affording a point " 
entry for syphilitic or chancroidal virus; “ cold sores” 
on the lips may also receive infection from mucous 


INFLAMMATORY AFFECTIONS. 133 


patches. Herpes gestationis is very apt to recur 
with each succeeding pregnancy. 

Treatment.—In most cases little internal treatment 
is required, other than a cooling laxative, as citrate 
of magnesia or the mineral waters; in herpes iris a 
nervous breakdown may be the cause of the erup- 
tion, and in this, as in herpes gestationis, strong nerve 
tonics and arsenic are of much service (Formule 58, 
60, 64). Soothing and protective lotions and oint- 
ments (Formule 25, 26, 27, 28, 30, 83, 84, 85,95) are 
of value; tannin in ointment (Formula 87) or lotion 
(Formula 22), assists in warding off herpes prepu- 
tialis. These raw points should never be cauterized. 
In herpes gestationis, in addition to cooling lotions 
and ointments, great relief to the itching may be ob- 
. tained from the liquor picis alkalinus (Formula 42) 
diluted ten to twenty times, more or less, followed 
by a protective ointment (Formule 83, 84, 85). 


IV. BULLOUS ERUPTIONS. 


Three affections are thus classed, namely, hydroa, 
pemphigus, and pompholix. 


7. Hydroa. The term hydroa is of recent intro- 
duction, and its exact use is by no means yet set- 
tled. It is employed mainly to represent a class of 
cases characterized by the occurrence of bulle of 
various sizes, generally small, which can hardly be 
grouped with herpes, nor yet with pemphigus; the 

i 


154 MANUAL OF DISEASES OF THE SKIN. 


eruption is very apt to recur, and is often associated 
with the gouty habit. ‘There is room for doubt as 
to the propriety of making a separate affection by 
this name, as many of the cases thus reported appear 
to be related to bullous urticaria, erythema multi- 
forme, herpes tris, or pemphigus. 

The ¢reatment is to be guided by the conditions 
present, and is the same as is of value in similar 
eruptions. 


8. Pemphigus. Pemphigus is essentially an 
eruption of bullz, but under certain conditions these 
become so altered as to be hardly recognizable, 
while in many cases they form a striking and almost 
startling feature. Two forms of the disease are re- 
cognized, pemphigus vulgarisand pemphigus foliaceus. 

. PEMPHIGUS VULGARIS may attack any or all por- 
tions of the body; different cases differ very greatly 
in their severity and extent. The bulle generally de- 
velop rapidly, and often blisters of great size form 
in a day; the contents soon become purulent; there 
is but little inflammation at the base or around 
them. In certain cases there is a strong tendency 
to ulcerate, and each bleb may become the seat of a 
diphtheritic appearing membrane, refusing to heal. 

PEMPHIGUS FOLIACEUS.—The appearance exhib- 
ited by this eruption, when of any duration, would 
hardly suggest the bullous character of the disease. 
The surface presents a raw condition, with nu- 


INFLAMMATORY AFFECTIONS. 158 


merous, partially attached, thin sheets of epider- 
mis; these have resulted from ruptured bulla, or 
from such as have but imperfectly formed. The 
course of this eruption is most chronic and rebel- 
lious to treatment ; the patient suffers greatly and 
finally succumbs. 

The term pemphigus pruriginosus has been applied 
to the eruption of herpes gestationis; pemphigus 
malignus, cachecticus, and gangrenosus relate to 
severe cases and lowered vitality. 

Diagnosis.—Bullze are observed in a number of 
affections, dermatitis, hydroa, erythema multiforme, 
urticaria bullosa, erysipelas, pompholix, syphilis, and 
sometimesin scabies and lepra ; moreover they arise 
in some persons upon very slight local irritation. 
But it is to be remembered that the characteristic 
lesion of pemphigusis a bulla, whereas in other erup- 
tions this is a secondary matter, and other lesions 
are present. Pemphigus foliaceus resembles chronic 
general eczema and dermatitis exfoliativa. 

Prognosis.—This is always grave except in very 
mild cases. , 

Treatment.—There is one remedy which has a 
very great power over pemphigus, and that is arsenic ; 
given rightly, it is almost a specific. To be effective 
it must be administered with a free hand, given 
every two or three hours, even in doses sufficient to 
act on the bowels, or to cause its physiological ef- 
fects on the eyes and stomach, if the eruption does 


156: MANUAL OF DISEASES OF THE SKIN. 


not yield sooner; it is well administered in Vichy 
_ water, and the liquor sodze arseniatis is preferable to 
Fowler’s solution. Tonics are also called for, and 
most nutritious diet. Locally it is to be remem- 
bered that the epidermis forms the best covering 
for the abraded surface, and therefore if the bulle 
are evacuated, as is often necessary to relieve the 
tense distress, they should be disturbed as little as 
possible. Evaporating lotions, containing powdery 
sediments (Formule 25, 26, 28, 30), give considera- 
ble relief ; raw places are to be dressed with sooth- 
ing ointments (Formule 83, 84, 85). When there is 
itching the liquor picis alkalinus (Formula 42), diluted 
ten or more times, gives great relief, either alone or 
added to other lotions. 


9. Pompholix. Synonym: Chetro-pompholix. This 
is another eruption of recent definition about 
which opinion is still unsettled. It consists of an 
eruption upon the hands or feet of deep seated ves- 
icles which may develop into bulle; these often are 
seated along the sides and backs of the fingers, and 
also occur on the palms and about the ankles. The 
appearance of the vesicles and blebs is preceded by 
burning and tingling, and there is little inflamma- 
tion attending the process; there is also very little 
tendency for the later development of anything like 
eczematous surfaces, but the lesions incline to dry 
up shortly. This condition is believed to be differ- 


INFLAMMATORY AFFECTIONS. 187 


ent from the dyszdrosis of Tilbury Fox, which is de- 
scribed among diseases of the perspiratory glands. 

Diagnosis—The eruption resembles eczema, also 
dysidrosis, and could be mistaken for scabies. 

Prognosts.—There is a strong tendency to recur in 
pompholix ; separate attacks yield readily. 

Treatment.—Arsenic has a very considerable con- 
trol over the eruption, and arrests its development ; 
strychnia, quinia, and nerve tonics, together with 
cod-liver oil and good diet, form the treatment of 
most service. In acute attacks a purge and an alka- 
line tonic (Formule 52, 53, 55, 65), give the most 
immediate relief. Locally, cooling lotions and mildly 
astringent ointments (Formule 25, 26, 28, 85, 87, 94) 
serve to relieve the condition. 


V. PUSTULAR ERUPTIONS. 


Four distinct diseases are placed here, whose 
characteristic lesion is a pustule; these are sycosts, 
impetigo, tmpetigo contagiosa, and ecthyma. 


10. Sycosis. Synonyms: Sycoszs non-parasitica ; 
Folliculitis pilorum, Mentagra,; Acne mentagra. 
Sycosis is an inflammation around and in the hair fol- 
licles, principally of the hairy face, exhibiting pustules, 
penetrated each by a hair, accompanied by pain and 
burning sensations. This disease must be carefully 
differentiated from parasitic sycosis, a form of ring- 
worm often known as barber’s itch, described under 


158 MANUAL OF DISEASES OF THE SKIN, 


parasitic diseases astinea trichophytina barbe. Syco- 
sis begins with a deep seated stinging or burning pain, 
which is shortly followed by the appearance of red 
points which quickly show signs of pus; later the 
inflammation becomes more general, the inter-fol- 
licular tissue is involved, and a more evenly red- 
dened surface may occur, or even a succulent, tuber- 
cular, or fungoid condition: This latter, however, 
belongs rather to tinea barbz or the parasitic erup- 
tion. of hairy parts. 

Sycosis being a peri-folliculitis at first, when pus 
appears at thesurface it has traversed the follicle ; the 
hair is, therefore, found to be detached and easily ex- 
tracted from its seat, together with a mass of suc- 
culent epithelial cells composing its root-sheaths, 
which are infiltrated with pus and serum. Another 
sign relating to the deep-seated inflammation is ex- 
hibited in a tenderness when the hairs are seized 
and pushed in, or lightly drawn on, there being a sore- 
ness felt which is quite different from the sensations 
belonging to other affections. As aresult of the 
thorough involvement of the follicle from beneath, 
there is not infrequently permanent baldness from 
sycosis. The most common region to be attacked 
is the sides of the face, also the chin, and upper lip, 
but it may also affect any part of the body where 
there are large hairs. 

Etiology.—This is little understood; the eruption 
often appears quite unconnected with apparent. 


INFLAMMATORY AFFECTIONS. I59 


local cause; while it is more common in those who. 
have recently ceased shaving, it is also observed in 
those who have never shaved, or not for many 
years, and in those who shave daily; it is not con- 
tagious. It is often observed in those exhibiting an 
eczematous habit, and commonly seems to be con- 
nected with digestive derangements. 

Diagnosis.—Sycosis often resembles eczema of 
hairy parts very strongly; it may also be con- 
founded with ¢znea barbe, acne, and an eruption of 
syphilis. 

Prognosis —This should always be guarded, for 
the eruption is apt to be most rebellious. 

Treatment.—The internal measures are largely 
those applicable in eczema, with which the disease 
has close affinity; arsenic often seems to have a 
controlling influence; when there is much old thick- 
ening, small doses of mercury are of service. The 
local treatment is all important. First is the re- 
moval of the hair; when pustules are formed the 
haits in them, should be extracted, but if much pain 
is caused the hairs should not be taken out, the. 
object being only to remove loosened hairs and to 
permit the escape of pus. Next, the part must, in 
most cases, be shaved, and that even every day. 
The operation is painful at first, but is soon pre- 
ferred by the patient; when only clipped short the 
stiff hairs irritate the deep portions as they are 
pressed on in making dressings. The most service- 


160 MANUAL OF DISEASES OF THE SKIN. 


able application is the diachylon ointment (For- 
mulz 94, 95) spread on the woolly side of lint, and 
bound firmly on the part. If this cannot be worn 
during the day, it may be wiped off, and an oint- 
ment of calamine (Formula 84), spread lightly on, 
may be substituted. In the more acute stages it 
should be treated like pustular eczema, and when 
more chronic, stimulant and absorbent applications 
(Formule I9, 92, 102) may be employed. 


11. Impetigo. In former times many cases of 
pustular eczema were thus named, but at the pres- 
ent time a limited but definite application is made 
of the term impetigo, while some observers discard 
it entirely. Practically, however, cases are met with 
which exhibit pustules which are peculiar, and. do 
not belong to eczema or to any other recognized con- 
dition. The pustules of impetigo are separate, superfi- 
cial, and small, with a comparatively insignificant 
amount of surrounding inflammatory action; they 
tend to dry into yellow crusts, and, if undisturbed, 
heal kindly. This eruption is more frequently seen 
among the poor, and especially among children; it 
is most common on the face and hands, but may 
affect any portion of the body. 

INagnosis—The eruption resembles pustular or 
impetiginous eczema, tmpetigo contagiosa, scabies, the 
lesions accompanying phthiriasis, and pustular sy- 
philis. 


INFLAMMATORY AFFECTIONS. 161 


Prognosis—This is invariably good, if properly 
treated, but if neglected the pustules may continue 
to be produced for a Jong time. Unless greatly 
irritated and caused to ulcerate, they do not leave 
cicatrices. 

Treatment.—This is essentially that of eczema; 
as‘far as known, the causes are the same. The pro- 
cess is inflammatory, and the mildest and the most 
soothing local measures must be employed. 


12. Impetigo contagiosa. All pus is more or 
less inoculable, but in this affection there appears 
to be a contagious principle which propagates the 
_ disease, both on the affected person and others: it 
is supposed to be local in its action, the system not 
being affected. ) 

The eruption resembles ordinary impetigo, but is 
characterized by the superficial nature of the lesions, 
which consists of flat vesico-pustules, which rapidly 
dry into yellow, friable, brown-paper-like crusts. 
They may be isolated or grouped together, and vary 
in size from that of a small split pea to that of a 
finger nail. Beneath the scabs the surface is moist, 
and secretes a little pus, and heals without a scar. 
The most common locations are the face and hands, 
but any portion may be attacked, it usually spread- 
ing from above downwards; children are most fre- 
quently attacked, and sometimes it appears in a 
number of cases in a community. 


162 MANUAL OF DISEASES OF THE SKIN. 


Some recent writers have revived the old term 
porrigo as a synonym for a pustular eruption of 
the scalp; the descriptions of porrigo in older 
books are so uncertain, that it is hardly possible to 
recognize what was meant. Many diseases, eczema, © 
phthiriasis, favus, etc., were formerly thus con- 
founded. | 
' Etiology —The cause is supposed by some to be 
a vegetable parasite, but the reports in regard to it 
differ so much that it is probable that the elements 
found in the crusts were accidental. 

Diagnosts.—The eruption may be mistaken for 
impetigo, pustular eczema, hydroa, varicella, and a 
pustular syphiloderm., 

Prognosis.—The eruption is almost self-limited, 
running its course in a week or two, if not subjected 
to irritation. 

Treatment.—Mild laxatives and correctives are of 
service, followed by tonics, as it is seen most com- 
monly in those in a lowered state of health. Lo- 
cally only the mildest ointments are required (For- 
mulz 85, 86, 90, 91); a very weak white precipitate 
ointment answers best, with a little carbolic lotion 
(1: 20) if it does not yield. 


13. Ecthyma. This is characterized by larger 
and deeper pustules than those of the preceding 
eruptions, seated upon a more inflamed base, leav- 
ing excoriations and temporary scars; ecthyma dif- 


» 


INFLAMMATORY AFFECTIONS. 163 


fers from a boil in not having a central core of necrosed 
tissue. The pustules may appear singly or scattered 
over much of the body; they are highly inflamma-. 
tory, and often cause considerable pain. Lesions 
resembling ecthyma appear in syphilis, scabies, and 
phthiriasis, but are excluded in the present under- 
standing of the eruption. It occurs most commonly 
among the poor, and is often the result of neglect 
and filth; scratching often plays a prominent part 
in its causation and continuance. 

_ Diagnosis —Ecthyma resembles the large flat pus- 
tular syphiloderm, also the lesions seen in scadzes and 
phthiriasis, also impetigo, wnpetigo contagiosa, and 
pustular eczema. 

Prognosis.—The state is entirely curable, and there — 
is no particular tendency to relapse. 

Treatment.—Powerful tonic remedies are called 
for (Formule 52, 58, 59), care being also taken of 
the emunctories, and that the diet is most nutri- 
tious, with the avoidance of stimulants and tobacco. 

Locally, soothing and slightly stimulant applications 
(Formule 84, 85, 88) are called for, together with 
perfect cleanliness. 


CHAPTER AX: 


CLASS IV. EXSUDATIONES.—EXUDATIVE OR INFLAM. 
MATORY AFFECTIONS.—( Continued.) 


VI. MULTIFORM ERUPTIONS. 


WHILE syphilis, scabies, erythema multiforme, and 
perhaps some other eruptions may be polymor- 
phous, there are but two whose essential character 
is recognized as such in the classification employed; 
these are eczema and dermatitis. ‘These two often 
resemble each other very closely, but, as will appear 
later, it is very important that they should be dif- 
ferentiated; dermatitis is a local inflammation, en- 
tirely due to local irritants, while eczema is a con- ° 
stitutional affection, in which it is often impossible 
to trace any local cause for the eruption. 


14. Eczema. Synonyms: Salt rheum ,; Morst tet- 
ter; Scall; Milk crust. Foremost among all dis- 
eases of the skin in importance, both from the num- 
bers affected and the distress occasioned, must 
always come this ever-varying eruption eczema. It 
attacks all classes and conditions, from the cradle 
to the grave, appears about equally in both sexes, 

164 


INFLAMMATORY AFFECTIONS. 165 


and comprises nearly one third of all cases that 
make up statistics; among the 8,000 cases here 
analyzed, eczema occurred 2,679 times, forming 
33-007 per cent. in” private. and=33:24. percent. in 
public practice; probably the real proportion is 
nearer one-half of all skin cases, inasmuch as many 
have it without seeking relief. 

Eczema may be defined as a non-contagious in- 
flammatory disease of the skin, of constitutional 
origin, acute or chronic in character, manifesting 
any or all of the results of inflammation at once or in 
succession, and accompanied with burning and itch- 
ing. As further details may be mentioned, the ten- 
dency to exude a serous discharge, which stiffens 
linen and dries into scales and crusts, and in later 
stages an infiltration or thickening of the skin, which 
then cracks, producing painful fissures. 

It will be seen that eczema is no longer regarded 
as a vesicular eruption, as formerly, but that its 
manifestations may be most varied. Among one 
hundred miscellaneous cases of acute and chronic 
eczema, not ten instances, if indeed five, would pre- 
sent a single well-marked vesicle when first pre- 
sented for treatment. The eruption may remain 
erythematous from first to last, or it may be papu- 
lar; or vesicles may be repeatedly formed, or the 
epidermis may be stripped off very quickly, leaving 
a raw, red surface; or, pustules may be freely de- 
veloped, isolated and distinct, or a purulent and dis- 


166 MANUAL OF DISEASES OF THE SKIN. 


charging surface may become covered with a crust; 
or, there may be a thickened and reddened tissue, 
more or less covered with thick scales. These phases 
and others will be more particularly described later. 
It will, however, be impossible to enter into all de- 
tails in the present compass; the manifestations of 
the disease are so varied and its elements of causa- 
tion so numerous, that even a brief statement of the 
subject must occupy many pages.* 

The earliest local phenomena in eczema are nerve 
and capillary disturbances, and the skin lesions are 
to be looked upon as secondary to these; eczema 
has been well spoken of as a catarrh of the skin, the 
exudative feature is rarely absent at some period in 
its course. 

There are six general symptoms of eczema, which 
it is well first to fix firmly in the mind: these are, 
1. Itching, pricking, or burning pain; 2. Redness 
from congestion; 3. Papules, vesicles, pustules, or 
exudation; 4. Crusting and scaling; 5. Infiltration, 
or thickening; 6. Fissures, or cracks. 

1. /tching.—The most prominent and constant 
symptom in eczema is the itching, which may be 
preceded by or give place toa burning pain. In 
some locations, and in milder degrees of the com- 


* For a complete study of the disease, the reader is referred to the 
recent work by the writer on ‘‘ Eczema and its Management, A prac- 
tical treatise based on the study of 2,500 cases of the disease.” —8vo. 
pp. 344. -G. P. Putnam’s Sons, 1881. 


INFLAMMATORY AFFECTIONS. 167 


plaint, the itching amounts only to a disagreeable 
tickling or pricking, as though a minute insect were 
beneath the skin, while in other cases the sensation 
is insupportable, and nothing will allay it but the 
most severe, deep, and thorough scratching. This 
symptom of cutaneous irritation is placed first, be- 
cause of its very great importance in causing and 
perpetuating the eruption of eczema. Often the 
itching will appear to be the only symptom, and the 
lesions will develop after scratching; often, again, 
some itching will remain after external appearances 
have subsided. The itching is always worse when 
the parts are exposed to the air. 

2. Redness from congestion.—This is an essential 
element of the eruption, dependent upon the nature 
of the process; there is almost invariably an eleva. 
tion of temperature in the part affected. This red- 
ness disappears momentarily on pressure; after it 
has continued some time a yellowish staining re- 
mains. 

3. Papules, vesicles, pustules, or exudation. Eczema 
being an inflammatory eruption of the catarrhal 
type, the exudation takes place in the upper por- 
tion of the corium and deeper layers of the rete. If 
the process goes no further, there is only erythema- 
tous redness, with infiltration or thickening of tissue, 
and consequent scaling. When the congestion and 
exudation are localized, small solid papules of plas- 
tic matter are formed; if the fluid is more abundant 


168 MANUAL OF DISEASES OF THE SKIN. 


and less plastic, it raises the epidermis, and vesicles 
result, or pustules when the inflammation is intense 
or the vitality lowered; after the diseased patch has 
been bereft of its normal epidermis, the fluid exudes 
_ directly from the surface, and forms the “ watering,” 
‘“‘leeting,”’ or discharging feature belonging to cer- 
tain phases of the eruption (eczema madidans). In 
some cases this moist stage occurs almost immedi- 
ately, the epidermis being shed in a mass. 
4. Crusting and scaling—-The exudate of eczema, 
which stiffens and stains linen, has a very strong 
tendency to dry into crusts and scales. If a dis- 
charging surface is left exposed to the air it soon 
becomes glazed over and slippery, but dry, in place 
of being sticky; this coating increases from beneath, 
and forms scales or crusts of varying thickness. Es- 
pecially in infants, as in “ milk crust,” and upon the 
scalp, the masses may be very great; on removing 
them the surface is still moist beneath. Another 
condition of scaliness is seen where, without any 
previous moist stage, the epidermis is continually 
shed from a more or less reddened base, as upon 
the scalp, forming “ dandruff,” in erythematous 
eczema. | 
5. (Infiltration, or thickening.—This belongs princi- 
pally to chronic eczema, but is seen more or less in 
every case; the skin then acquires a hard, leathery 
condition, and the increased thickness is recognized 
by comparing a fold of diseased integument with 


INFLAMMA TORY AFFECTIONS. 169 


a corresponding portion of unaffected skin. This 
thickening may extend even through the entire co- 
rium, and on the legs simulates elephantiasis Ara- 
bum. 

6. Fussures, or cracks—Closely connected with and 
dependent upon the last symptom, are the fissures 
or cracks, which occur in localities where eczematous 
skin is called on to stretch and bend, as on the 
knuckles and palms, behind the ears, and elsewhere. 
The infiltration of the corium with the products of 
inflammation renders the fibres, which should be 
very elastic, dense and hard; and the inflammatory 
cells, without cohesive power, scattered among the 
fibres, weakens what strength is left.. Sometimes 
cracks on the ends of the fingers appear to be the 
only sign of eczematous disease. 


In regard to the names given to the varieties and 
forms of eczema, there has been too much confu- 
sion, and too great stress is laid upon them; the 
disease is one and the same, although the external 
manifestations may vary greatly in different pa- 
tients, or even in the same case at different times, 
and also according to the locality. The various 
names which are found in literature connected with 
eczema amount to about one hundred and eighty, 
given mostly to express various features in the erup- 
tion. They relate to five elements of importance in 
the consideration of the disease, namely, 1. The 

8 


170 MANUAL OF DISEASES OF THE SKIN. 


stage of the eruption; 2. The lesion present; 3. 
‘The location of the eruption; 4. The condition of 
the diseased part; 5. The cause. A sixth group 
may be made of miscellaneous popular and other 
names. The actual name employed is of little im- 
portance, provided the condition represented be 
understood, which is very important both for diag- 
nosis and treatment. : 

The first element is the stage or state of the ex- 
isting eruption. Three general divisions may be 
here made, namely, into acute, sub-acute, and chronic 
eczema, the same case may present each phase, 
either at the same time in different localities, or at 
different times. 

ACUTE ECZEMA is characterized by heat, burning, 
and tingling, with redness and cedema, which latter 
may be considerable where the skin is lax. Shortly 
papules and vesicles may appear, or the epidermis 
may be stripped off, leaving a raw, exuding surface ; 
or, the process may remain erythematous to the end. 
Acute eczema resembles dermatitis very greatly, and 
it is often impossible to determine the true charac- 
ter at-once) li the eruptionvoft acute -eczemais 
protected, or not further irritated, it tends to sub- 
side in a few days, but not completely, for the erup- 
tion lingers in a less acute condition, and is apt to 
pass into the state next described. 

SUB-ACUTE ECZEMA refers to a less inflammatory 
condition, with a reddened, itchy surface, and mod- 


INFLAMMATORY AFFECTIONS. 171 


erate thickening; the diseased portions may be 
moist, tending to become scaly or crusted, or they 
are hard and papular, exuding a glairy fluid when 
scratched. 

CHRONIC ECZEMA.—This term is applied both to 
an eruption of long duration, and to the condition 
which usually obtains in old cases; it is character- 
ized by reddened and thickened skin, which itches 
furiously, and may desquamate freely, or exude if 
scratched. Where there is motion there is a tend- 
ency to fissures, which may be very painful. Itching 
may be absent in particular cases of chronic eczema. 

The lines of demarcation between these three 
conditions are not well defined, but the distinction 
between the acute inflammatory state and the 
chronic, indolent condition must be remembered, 
as it is of great importance therapeutically; in the 
former the mildest soothing and astringent applica- 
tions are called for, in the latter very severe stimu- 
lation may be required. 


The second point to be considered is of especial im- 
portance diagnostically; this relates to the anatom- 
ical lesion constituting the eruption; and here we 
may have four varieties or conditions of eruption; 
eczema erythematosum, e. papulosum, e. vesiculosum, 
and ¢. pustulosum. ‘There are also certain other forms 
of eczema which are commonly recognized. as eczema 
madidans, e. squamosum, e. sclerosum, and e. fissum. 


172 MANUAL OF DISEASES OF THE SKIN, 


ECZEMA ERYTHEMATOSUM is marked from first to 
last by the erythema-like character of its lesion: 
there is always some infiltration, and the surface has 
a harsh, leathery feel, and may be more or less scaly. 

ECZEMA PAPULOSUM.—The lesion is here com- 
posed of papules, perhaps existing alone, or com- 
bined with the former condition, or with occasional 
vesicles: many cases which were formerly called 
lichen are now recognized to be papular eczema. 

ECZEMA VESICULOSUM.—Typical vesicular eczema 
is comparatively rare, and is generally acute; more 
commonly the vesicles have already broken down 
into moist surfaces, or hard patches, when presented 
for treatment. Where the epidermis is thick, as on 
the palmar surface of the hand and fingers, the vesi- 
cles appear as pearly, or boiled-sago-like points; the 
burning and stinging is generally relieved when 
vesicles are formed, and often ceases when they dis- 
charge. ; 

ECZEMA PUSTULOSUM.—Here pustules take the 
place of vesicles, either from the intensity of the in- 
flammation, or from the lowered or strumous condi- 
_ tion of the patient. As in vesicular eczema, the separ- 
ate elements are often not visible, and what is called 
pustular eczema, as seen in “‘ mz/k crust” in infants, 
presents a mass of yellow crusts only; many cases 
which were formerly called zmpetigo are now recog- 
nized as pustular or tmpetiginous eczema. Pustular 
eczema of hairy parts seldom itches much. 


“INFLAMMATORY AFFECTIONS. 173 


These four conditions may be spoken of as pri- 
mary lesions of eczema. The following terms are ° 
used to express-the pathological states presented 
clinically as secondary to the preceding: 

ECZEMA MADIDANS, or eczema rubrum, results 
from a shedding of the epidermis, which may be 
either the result of a chronic eczematous process, or 
may occur acutely. The denuded and diseased rete 
malpighii if irritated may give exit to vast quanti- 
ties of serum, or the exudate dries into crusty scales, 
upon a moist base: it is often observed typically on 
the lower legs. 

ECZEMA SQUAMOSUM.—This represents a secon- 
dary stage following many conditions: there is a 
continuous exfoliation of epidermis, generally from 
a reddened surface. 

ECZEMA SCLEROSUM.—This relates to the thick- 
ening of skin, which sometimes forms almost the sole 
feature of the case, as upon the palms and soles, and 
finger tips. This form leads to the next: 

I.CZEMA FISSUM, or RIMOSUM presents cracks of 
varying size and depth, often very painful: upon the 
ends of the fingers the hardening and fissuring are 
quite peculiar (eczéma fendillé). 

The next consideration relates to the location of 
the eruption, which may be of importance diagnosti- 
cally and therapeutically ; in both of these aspects 
the eruption will now be considered in the various 
localities. 


174 MANUAL OF DISEASES OF THE SKIN. 


ECZEMA OF THE FACE AND SCALP.—The face and 
scalp are very common seats of the eruption in in- 
fants; at first it appears as an itchy, reddened patch, 
with a few papules which are quickly torn, and a 
raw, exuding surface results, which soon becomes 
covered with crusts, to be again torn off by scratch- 
ing; the surface rapidly increases in size until a large 
portion of the face and scalp may be affected. In 
adults the eruption commonly assumes the erythe- 
matous or papular forms on the face, or a pustular 
one upon hairy parts. Erythematous eczema of 
the face is very frequently mistaken for eryszfelas, 
or erythema. Papular eczema may resemble acne 
rosacea, or a small, grouped papular syphiloderm. 

Eczema of the eye/zds is sometimes a very trouble- 
some affection; its real nature often passes unrecog- 
nized, and it is often regarded asa simple blepharitis, 
and proves rebellious until proper constitutional 
treatment is instituted. The edges of the lids are 
thickened and red, and the lashes glued together. 

Eczema of the “zfs may exist alone, affecting the 
skin or the vermillion border; about the mouth 
erythematons eczema is very rebellious, owing to the 
constant movements of the part. Eczema of the 
upper lip is often closely connected with, if not de- 
pendent upon, an irritating discharge from the nose. 

Eczema of the ears is not uncommon in children, 
,and behind the ears it is also common in adults; 
chronic eczema of the external auditory canal is 


INFLAMMATORY AFFECTIONS. 175 


not infrequent, but often unrecognized. When 
acutely affected the ears are greatly swollen, hot and 
painful; in a chronic state of eczema they are moist, 
thickened, and itchy. Behind the ear the eruption 
is very apt to linger fora long time, causing annoy-. 
ing cracks. 

Upon the scalp eczema may be seen in three 
phases : pustular, moist exuding,and dry scaly. Pus- 
tular or impetiginous eczema is common in young 
persons, presenting separate pustules, or more often 
only crusts, which mat the hair together, with a moist 
surface beneath. In moist or exuding eczema of 
the scalp the hairs are often stiffened as though from 
mucilage ; the condition may remain some period 
of time or may pass quickly into the next form. 
Squamous or scaly eczema exhibits many phases and 
degrees - often it is but a later stage of other forms, 
but it may also appear to be a primary affair, slowly 
increasing from a moderate scaling, until what at first 
appeared as a mild dandruff becomes annoying in 
the extreme, by the ee and the constant shed- 
ding of scales. 

Diagnosis.—Eczema of the face may be confound- 
ed with erythema, acne rosacea, and erystpelas ; in the 
beard, with sycos¢s and tinea barbe (or parasitis syco- 
sis). Upon the lips it may be mistaken for sypheletec 
mucous patches, especially at the corners of the 
mouth, and for herpes labialis. Pustular eczema 
of the scalp may resemble phthiriasis, a pustular 


176 MANUAL OF DISEASES OF THE SKIN. 


syphiloderm, and crusted favus; scaly eczema of 
the scalp resembles seborrhea, pityriasis, psoriasis, 
tinea tonsurans, and old cases of favus. 

Treatment.—The treatment of eczema of the face 
and scalp should be essentially soothing and astrin- 
gent. Tannin ointment (Formula 87), is especially 
suited to the scalp; it should be applied freely and 
left on, the part being washed very seldom, with tar 
soap, and the ointment reapplied within a few 
minutes after the washing. In using stimulant 
lotions subsequently (Formule 49, 50, 51), to pro- 
mote the growth of the hair, care must be taken not 
to overstimulate. 

The face is a difficult portion to treat, and bears 
stimulation poorly. During more acute stages sooth- 
ing lotions and ointments (Formule 25, 26, 28, 83, 
84, 85) are required; later those containing tar are 
of service to relieve the itching (Formule 88, go). 
In eczema of the beard daily shaving with Pear’s 
transparent soap, and the continuous application of 
a calamine or diachylon ointment (Formule 84, 94, 
95) give the best results. * 

ECZEMA OF THE HANDS AND ARMS.—The erup- 
tion is very rebellious on the hands, owing to their 
exposure to air and water, the great motion of the 
parts, and the difficulty in keeping dressings applied. 
Acute eczema may exhibit much inflammation and 
considerable cedema: more commonly the eruption is 
sub-acute or chronic, with the repeated production of 


INFLAMMATORY AFFECTIONS. 177 


papules, and raw, hard patches, with fissures. On 
the palms (and soles) chronic eczema presents a stiff, 
hard surface, reddened or not, with a ragged scaling, 
and cracks, usually very painful, combined with itch- 
ing which may be distressing. The diagnosis be- 
tween this and palmar syphilis is often very difficult ; 
as a rule the eruption of syphilis is more sharply de- 
fined than that of eczema, with a decided tendency 
to clear in the center and to spread peripherally. 
The margin of the syphilitic eruption is composed 
of separate elements, papules or tubercles, and the 
cracks are usually through these; whereas those in 
eczema may occur anywhere and in any direction 
through the thickened skin. | 

Eczema of the arms exhibits the features of ec- 
zema elsewhere; at the bends of the elbows it is 
apt to present evenly reddened surfaces, very itchy, 
exuding freely when scratched. Elsewhere the 
eruption is usually papular or in patches of red- 
dened and moderately thickened. tissue. A very 
scattered papular eruption on the forearms should 
always suggest scabies. 

Diagnosis —Eczema of the backs of the hands 
may be mistaken for scabies, dysidrosts, lichen planus, 
and erythema papulatum ; on the palms (and soles) 
the condition suggests scleroderma, syphilis, and pso- 
r1asis. 

Treatment.—This varies greatly with the condi- 


tion present; in the more acute form of the erup- 
g* 


178 MANUAL OF DISEASES OF THE SKIN. 


tion, envelopment of the hand and arm in a bag 
containing buckwheat flour is most serviceable, also 
cooling and astringent lotions and ointments (For- 
mulz 25, 26, 28, 30, 83, 84, 85). In sub-acute states 
an ointment with tar is of most service (Formule 
88, 89). The chronic forms resist severe stimula- 
tion, and blistering will often be required. The 
compound tincture of green soap (Formula 39), well 
rubbed on with flannel or with a brush, and followed 
by a soothing ointment (Formule 83, 84, 85), will 
sometimes accomplish much; often this aggravates 
.the trouble, and solutions of caustic potash (For- 
mula 16) used similarly, are best borne. Eczema of 
the palms is greatly benefited by soaking the part 
on the surface of very hot water, for a few min- 
utes, and the subsequent application of diachylon 
ointment (Formule 94, 95) spread on lint and bound 
firmly on; in some cases a mercurial application is 
of the most service (Formule go, 102). 

ECZEMA OF THE FEET AND LEGS.—The eruption 
in this locality is obstinate because of the relations 
of the parts to the circulatory system: the depend- 
ent position taken for so much of the time tends 
to produce and keep up congestion, and to hinder 
absorption. Upon the lower legs the eruption is 
usually seen in the form of what is known as eczema 
rubrum or madidans, exhibiting a red, raw, and 
tender surface, exuding greatly if irritated, but also 
tending to cover itself with imperfectly formed epi- 


INFLAMMATORY AFFECTIONS, 179 


dermal scales and crusts. The itching is often most 
distressing, and there is frequently great soreness 
and pain from the accompanying varicose veins. 
Ulcers of the leg are frequently associated with 
eczema, ancdare due-to-the same causes.. YEczema 
may also appear upon the legs in all the ordinary 
forms, and is often seen in scattered or grouped 
papular eruptions; in the popliteal spaces it may be 
so severe as to impede walking. 

Upon the feet eczema often exhibits vesicles, es- 
pecially on the toes; chronic hard patches also often 
occur about the ankles, which are very rebellious. 
On the soles the eruption resembles that on the 
palms. 

Diagnosts—Eczematous and varicose ulcers may 
frequently be confounded with the lesions of syphilzs, 
as also may the eruption on the soles; eruptions 
about the toes and ankles of children should always 
suggest scadbtes. 

Treatment.—The treatment of eczema and ulcers 
of the leg has been much simplified since the intro- 
duction of the rubber bandage; it is of almost uni- 
versal application. It is applied directly upon the 
diseased surface, not too tightly, and worn during 
the day; at night the surface is gently wiped with 
a damp cloth and, if necessary, a soothing lotion or 
an ointment (Formule 25, 26, 28, 83, 84, 85) applied. 
The bandage, having been washed on removal and 
aired all night, is re-applied while in bed, after the 


180 MANUAL OF DISEASES OF THE SKIN. 


dressing for the night has been removed, and any 
ointment gently wped off; as grease and glycerine 
soon destroy the bandage. In more chronic cases 
the application of caustic potash, or green soap, 
alone or in solution or with tar, or the liquor picis 
alkalinus in varying strength (Formule 16, 38, 39, 
42) are of service, always to be followed by sooth- 
ing applications (Formule 83, 84, 85). Eczema of 
the feet yields well to tar and zinc ointment, and 
later to tannin and diachylon ointments (Formule 
87, 88, 94, 95): 

ECZEMA OF THE ANUS AND GENITAL REGION is 
most intractable if wrongly treated, and very man- 
ageable if all is done rightly. Internal treatment is 
specially important. The eruption manifests vari- 
ous degrees of severity, from a moderately itchy, 
soddened condition around the anus, to a severely 
raw eczematous surface, involving many square inches 
of this region. Many cases formerly called prurigo 
podicis and prurigo scrott are now recognized as ec- 
zema. The thickening is very manifest upon the 
scrotum, and the element of cracking is very com- 
mon at the anus; the itching from eczema in this 
region may be excruciating. 

Diagnosis.—This is generally not difficult; the 
most important lesion to bear in mind is the ring- 
worm of this region, ¢zuca trichophytina crurts, the 
so-called eczema marginatum, already described un- 
der parasitic diseases. Phthiriasis pubis should be 


INFLAMMATORY AFFECTIONS. 181 


excluded, also syphilitic lesions, mucous patches and 
others ; likewise scabies, which may give rise to in- 
flamed points on the penis. 

Lreatment.—The internal and dietary treatment 
are of the greatest weight, but proper local measures 
are also very important, both in regard to the act- 
ual measures employed and the method of their use. 
The most universally serviceable application in 
chronic eczema of this region is the ointment of tar 
and zinc (Formula 88); this is to be spread thickly 
on the woolly side of lint and bound on the parts, 
after they have been soaked for a few minutes with 
a cloth dipped in very hot water. The dressing is 
to be changed twice daily, but the hot water applied 
only at bed-time. Other local measures are also of | 
service, as the calamine lotion (Formula 25), fol- 
lowed by the free application of Fuller’s earth or 
other powders (Formule 78, 80); later, stimulation 
with the compound tincture of green soap (Formula 
39), followed by a soothing ointment (Formule 83, 
84,85). Especial attention must be paid to the con- 
dition of the liver, bowels, and kidneys, and sulphur 
with cream of tartar taken freely at bedtime is a very 
important aid. 

ECZEMA OF THE TRUNK AND GENERAL ECZEMA.— 
On the body the eruption may take many phases; 
papular and erythematous eczema are most com- 
mon. Beneath the breasts raw, moist surfaces are 
apt to form very rapidly, and disappear quite as 


182 MANUAL OF DISEASES OF THE SKIN, 


quickly under proper measures. The region of the 
nipple is sometimes the seat of a condition resem- 
bling eczema, to which the name of “ Paget's disease” 
has been recently given, which is in reality an epith- 
elial degeneration, frequently ending in cancer. The 
umbilicus is occasionally the seat of an obstinate 
eczema, and the axille are sometimes affected toa 
very troublesome degree; boils and abscesses are 
not uncommon in the latter region, in connection 
with eczema. 

General eczema of the entire body, head and limbs 
is always a serious affair, especially in adults, and 
indicates profound depression. 

Diagnosis.—Eczema of the trunk may be mistaken 
for psoriasis, tinea, syphilis, zona, and pityriasis rubra. 
Eczema of the breast for “ Paget’s disease” or 
epithelioma, and scabies; eczema of the axille for 
ringworm of this region. 

Treatment.—The local measures do not differ from 
those detailed in regard to other portions of the 
body; baths (Formule 1, 2, 3) are particularly val- 
uable, together with the subsequent free use of an 
ointment, or cod-liver or linseed oil, with or without 
oil of cade (Formula 41). Laxatives and cooling 
alkaline mixtures (Formule 52, 53), followed by 
powerful tonics, are required. 

INFANTILE ECZEMA.—In children under five years 
of age the eruption of eczema is exhibited in its 
typical form, as far as the acute, raw, and exuding 


INFLAMMATORY AFFECTIONS. 183 


aspects are concerned. Beginning with a compara- 
tively small amount of papular or erythematous 
eruption, the condition may rapidly extend until the 
entire scalp and face, also the arms, legs, and much 
of the body, is the seat of a diseased cutaneous action. 
The surface of exposed parts is generally covered 
with crusts, which are frequently torn off, leaving a 
bleeding and exuding corium ; covered parts become 
more dry, generally adhere to dressings, and when 
these are forcibly removed exhibit a reddened, papu- 
lar surface, with numerous excoriated points, which 
sometimes bleed. The itching of infantile eczema 
is generally frightful, and the little sufferers become 
frantic in endeavors to get relief. 

Lreatment.—In the local treatment of infantile 
eczema the utmost care must be exercised to avoid 
over-stimulation of the affected part ; the measures 
must be soothing and astringent, and relief to the 
itching is to be looked for rather in carefully di- 
rected internal and dietary treatment and proper 
protection of the part than in applications which 
have any very great anti-pruritic effect. The tar and 
zinc-ointment (Formula 88) is a safe and valuable 
remedy if efficiently applied, spread on lint and 
bound on. ‘This should be removed twice daily, and 
on exposed surfaces the ointment is reapplied 
as often as rubbed off, even many times daily, to 
the entire exclusion of the air. Zinc and bismuth 
ointments, to which a little camphor or oil‘of cade 


184 MANUAL OF DISEASES OF THE SKIN. 


may be added (Formule 85, 86, 89), are also effi- 
cient remedies. Air and water are highly injurious 
to eczematous skin; the first is kept away by means 
of the ointment, the other by force of will. Ecze- 
matous skin should not be washed ; when this is ab- 
solutely necessary the part should be again instantly 
and thoroughly protected by ointment, after being 
very carefully and rapidly dried, without friction. 


Etwology.— Eczema appears to be hereditary in a 
comparatively small proportion of cases; it is not 
caused by infection or contagion; it is not directly 
due to malaria, but this element may be of impor- 
tance in certain cases; it is never wholly produced 
by external irritative agents without additional in- 
ternal conditions; as far as is known, it is not 
caused by any single article of diet; there is no 
one efficient, recognizable cause to which it can be 
always attributed. 

The causation has to do with two classes of ele- 
ments, constitutional and local, though the direct 
effect of the latter is often very difficult to trace. 
Eczema is eminently a disease of debility; this may 
be of three kinds, assimilative, nutritive, and ner- 
vous, or, as more commonly spoken of, gouty, stru- 
mous, and neurotic. By far the larger share of pa- 
tients with eczema exhibit what has been known as 
the gouty state ; that is, a condition of system tend- 
ing to gouty development, manifested by the most 


INFLAMMATORY AFFECTIONS. 185 


varied signs of imperfect assimilation and disinte- 
gration. The strumous and nervous states act also 
efficiently as predisposing causes of eczema. 

Local causes are found in any agencies which irri- 
tate and inflame the skin. Many cases seem to de- 
pend upon occupation, but it must ever be remem- 
bered that these local agents only suffice to cause an 
eczema in a very few of the persons exposed to them. 

Treatment.—The treatment of eczema is a very 
broad subject, reaching deeply into general medi- 
cine. Wilson has well said that “the highest and 
best qualities of medical art and science must be put 
in practice with foresight and discretion for the 
treatment of an eczema.’’ There is no specific for 
the disease ; arsenic will not cure it; the general 
state should be most rigidly studied, and remedies 
and measures suited thereto. Most eczema patients 
are benefited by alkalies, combined with bitter 
tonics (Formule 52, 53, 54, 55), together with judi- 
cious regulation of the action of the liver and the 
bowels (Formule 65, 66), although much purgation 
often does harm. Tonics are required later (For- 
mule 58, 59, 60, 64), and of these iron, strychnine, 
arsenic, and cod-liver oil hold the first place. But 
harm can often be done by tonics if the emunctories 
‘ do not act properly; the action of the skin as an 
organ must never be forgotten, and alkaline baths 
(Formule 1, 2, 3, 104) are of value in most cases of 
eczema. 


186 MANUAL OF DISEASES OF THE SKIN 


Diet and hygiene are of the utmost importance ; 
the benefits of most careful regulation of the diet 
are especially noticeable in infantile eczema, but the 
ill results from late errors in diet may be observed 
in almost all eczema cases. Sweets and starches 
in excess must be avoided, and fats encouraged. 
Exercise is all necessary in eczema. 

The local treatment has already been detailed in 
regard to the eruption in different localities; a few 
words may be added in reference to the principles 
governing its use. The main point to be remem- 
bered is the irritable nature of eczematous skin, and 
the danger of using too severe measures; it is far 
easier to increase the stimulation as required than 
‘to soothe a skin which has been unduly excited. In 
chronic eczema, however, very severe measures, even 
scrubbing with a brush and green soap, may be re- 
quired, but the subsequent treatment must be 
soothing. 

Air and water are irritating to skin affected with 
eczema; the effort must be made, therefore, to ex- 
clude the former by-proper dressing, while the latter 
is avoided; if washing is employed the part is to 
be at once protected by a proper dressing. Too fre- 
quent washing of an eczematous part will often keep 
up the eruption in spite of proper local measures. 

The mode of making local applications is often of 
great importance; as a rule ointments which are in- 
tended to be protective should not be rubbed on the 


INFLAMMATORY AFFECTIONS. 187 


diseased part, but spread on the wooly side of lint, 
and kept in elose apposition to the diseased surface. 
But in keeping them applied care must be exercised 
that the part be not overheated by warm wrappings. 

For more acute eczema, powders are applicable, 
and buckwheat flour forms one of the best dressings 
possible. Lotions which leave a powder on the skin 
(Formule 25, 26, 27) are also very grateful; some 
skins are irritated by the glycerine often used in 
them, which may then be replaced by almond emul- 
sion. In sub-acute and chronic conditions powders 
and mild lotions are almost useless, and ointments 
are called for, soothing, astringent, or stimulating; 
these are often combined with stimulating lotions, 
especially those containing tar (Formule 16, 39, 40, 
42), the lotion being wiped gently off with adamp 
cloth, if it burns. | 

Many mistakes are often made in endeavoring to 
relieve itching, stronger and stronger applications 
being employed only to the aggravation of the erup- 
tion, often, indeed, when the: mildest remedies will 
give relief. Tar and carbolic acid (Formule 84, 88) 
are valuable antipruritics; the liquor picis alkalinus 
(Formula 42), diluted ten times or more, is very ser- 
viceable, also chloral and camphor, in powder or 
ointment (Formule 81, 105). The tincture of gel- 
semium, taken internally in doses of ten drops, re- 
peated and increased, is often of great service, but 
is not well borne by every one. 


188 MANUAL OF DISEASES OF THE SKIN. ~* 


In the treatment of eczema, more is to be accom- 
plished by a careful study of the patient in every 
aspect, and the adaptation of remedies suitable to 
the condition found, than by the employment of 
any special prescription which is supposed to be of 
- value in the disease, or which is recommended by 
ever so high an authority. Attention to details is 
of the first importance in eczema, and the good ef- 
fect of even the best remedies may be frustrated by 
failure in some particular in the management of the 
case, while the best local application will often fail 
of its end, or even do harm, if wrongly employed. 

Dermatitis. This term is employed to designate 
inflammation of the skin from causes which are out- 
side of the economy; these may be either local irri- 
tants, or articles taken into the system, as food, 
drugs, or poisons. The lesions may be most varied, 
from the erythematous condition caused by heat or 
by mustard, to the large bulla sometimes following 
the interna! administration of iodide of potassium. 
Five varieties of dermatitis are recognized: dermatt- 
tis calorica, ad. traumatica, ad. gangrenosa, a. venenata, 
and ad. medicamentosa. 

DERMATITIS CALORICA.—The effects of heat and 
cold upon the skin vary with the individual and the 
degree of caloric; they exhibit various degrees of 
severity, from the milder sunburn and frosting, to a 
bullous eruption, or even death of the part. 

DERMATITIS TRAUMATICA.—Mechanical injury 


INFLAMMATORY AFFECTIONS. 189 


to the skin produces various lesions, from the mild 
congestive state caused by friction of the clothing, 
to pustular lesions due to scratching, or abrasions 
due to violence. The eruptions produced by lice 
and the itch mite are in reality dermatitis, but are 
described as phthiriasis and scabies. What is com- 
monly known as zuztertrigo is a local affair due to ir- 
ritation of the parts by confined and acrid secre- 
tions, with friction. 

DERMATITIS GANGRANOSA.—Under certain cir- 
cumstances gangrene affects the skin in circum- 
scribed patches; this may appear to occur sponta- 
neously, or as the result of injury, or it may follow 
lesions of nerves, even those which are far distant. 

DERMATITIS VENENATA.—Various external irri- 
tants are capable of exciting inflammation of the 
skin, often to avery severe degree; such are mus- 
tard, cantharides, mezereon, arnica, thapsia, tartar 
emetic, croton oil, and other substances used in med- 
icine; also certain dye stuffs, notably those from 
aniline and arsenic; likewise certain plants, es- 
pecially the rhus toxicodendron or fotson ivy or oak, 
and the rhus venenata, or potson sumac. These ar- 
tificial eruptions at times resemble acute eczema or 
erysipelas so closely that an immediate diagnosis is 
almost impossible. The eruption from the poison 
ivy and sumac is papular or finely vesicular, accom- 
panied with much redness and burning, and the dis- 
tress from it may be very great. It is usually sym- 


190 MANUAL OF DISEASES OF THE SKIN. 


metrical, on both hands and arms, and the face is 
generally affected, also the male genitals; it is far 
more common in children, and especially in those of 
light complexion and hair; often of a group of chil- 
dren of the same or different families the dark ones 
will escape, while those of fair skin will be affected. 

All these artificial eruptions tend to spontaneous 
recovery, if the cause is removed and the parts pro- 
tected, but in a certain number, thus disposed, 
eczema will result; in some cases the eruption from 
poison ivy and sumac will return very readily on 
each exposure, and instances occur where even rid- 
ing by the plant when in flower will suffice to excite 
a fresh attack. 

DERMATITIS MEDICAMENTOSA.—This term relates 
to the eruptions produced upon the skin by the in- 
gestion of certain drugs: facts in regard to seven- 
teen drugs have been collected by Van Harlingen,* 
to which full study, with a complete bibliography, 
reference may be made, as also to a careful pres- 
entation of the subject in Duhring’s Treatise on 
Diseases of the Skin. The drugs reported as having 
occasionally given rise to eruptions are as follows: 
arsenic, belladonna, bromine, cannabis indica, chloral, 
copaiba, cubebs, digitalis, iodine, mercury, opium, 
phosphoric acid, quinine, salicylic acid, santonine, 
strychnia, tar, carbolic acid and turpentine. 


* Archives of Dermatology, Vol. vi., No. 4, October, 1880. 


INFLAMMATORY AFFECTIONS, IQ! 


The eruptions caused by drugs vary greatly, from 
a slight erythema to papules, vesicles, pustules, 
-bullz, and even fungoid masses, as occasionally seen 
from bromide and iodide of potassium. At times 
‘they resemble very many diseases of the skin; the 
mottled eruption from quinine and copaiba may be 
mistaken for measles or the macular syphiloderm ; 
the pustular eruption from iodides and bromides re- 
sembles syphilitic and other eruptions, and the pur- 
pura from iodide of potassium can hardly be distin- 
guished from ordinary purpura. The lesions thus 
produced are liable to such variations that they can- 
not be detailed here; but, although they are rare 
effects, their possibility should always be borne in 
mind, especially if an eruption presents anomalous 
features. Under this head must also be classed the 
transient eruptions sometimes caused by the inges- 
tion of certain articles of diet; thus strawberries, or 
bananas, etc., will in some persons invariably cause 
an urticarial eruption, in others only under certain 
conditions. Stale fish, mushrooms, and various arti- 
cles of food at times excite erythematous and urti- 
carial conditions of the skin. 

In connection with the forms of dermatitis men- 
tioned, feigned eruptions should ever be borne in 
mind, that is, lesions artificially produced by the 
patient for the purpose of deception. These gener- 
ally occur in hysterical women, and a number of au- 
thentic cases are on record; the eruption may take 


1Q2 MANUAL OF DISEASES OF THE SKIN. 


the form of bullz, produced by acids, or abrasions 
of various degrees. Their true nature can usually 
be detected, suspicion first arising from their failure 
to correspond with recognized types of disease. 

Treatment.—The indications for treatment of all 
the forms of dermatitis are simple, namely, removal 
of the cause and protection of the affected parts ; 
there is more danger of doing-too much than too 
little. The eruptions from poison ivy and sumac 
are sometimes troublesome, as the poison seems to 
penetrate the skin and the eruption continues some 
time after what was perhaps a brief contact with the 
plant. Cooling lotions (Formule 25, 26, 27, 28, 48) 
are most acceptable, followed later by slightly astrin- 
gent ointments (Formule 84, 87). Duhring speaks 
of the fluid extract of grindelia robusta diluted thirty 
or forty times, as the best remedy. The eruptions 
caused by dyes in gloves, socks, etc., will often 
prove very troublesome; they are to be treated 
locally as an acute eczema. 


CHART ROR? a0; 


CLASS IV. EXSUDATIONES.—EXUDATIVE OR INFLAM- 
MATORY AFFECTIONS.—( Continued.) 


VII.—SQUAMOUS: ERUPTIONS. 


Three separate conditions are thus grouped, der- 
matitis exfoliativa (or pityriasis rubra), psorzasts, and 
pityriasis capitis: in these the scale, if it is not a 
primary lesion, is an inseparable element in the 
eruption. 


16. Dermatitis exfoliativa, or pityriasis rubra. By 
this is understood an inflammatory, non-contagious 
affection, involving a greater or less extent of sur- 
face, either continuously or in patches, characterized 
by a red, congestive color, and the production of a 
greater or less amount of branny scales. The process 
appears to be simply a congestive and slightly in- 
flammatory condition, which goes only to a desquam- 
ative stage, without thickening or exudation, as in 
eczema, and with comparatively little burning or 
itching. 

Various degrees and grades of this affection have 
been observed by different writers; Hebra is in- 

f, 193 


194 MANUAL OF DISEASES OF THE SKIN. 


clined to regard as pityriasis rubra only cases where 
a large share of the body is affected, and where the 
process thus becomes a severe one, generally fatal. 
Other observers have recorded milder degrees of the 
same condition, and with favorable prognosis; in 
certain cases the disease is limited to patches, to 
which the name fityriasts maculata et circinata has 
been given by Bazin, Duhring and others, while in 
other instances the eruption which has occupied 
larger tracts, has been characterized by a tendency to 
recur again and again. © 

Diagnosis.—Many eruptions | are characterized by 
redness and scaling, but the disease under consider- 
ation, when considered in its whole course will be 
found to differ materially from all other affections. 
It is most likely to be confounded with more or less 
general sguamous eczema, also with psoriasis, pem- 
phigus foliaceus, and lichen ruber ,; also possibly with 
tinea circinata and iinea versicolor. 

Treatment.—The eruption is rebellious to all the- 
rapeutic measures, and no single line of treatment 
can be recommended with prospect of great suc- 
cess. Milder cases yield to alkaline-and tonic reme- 
dies (Formule 52, 53, 58, 59), together with baths 
and emollients (Formule 1, 2,3, 41, 104); in the 
more severe cases constant envelopment in oil, as 
the linseed or cod-liver oil, affords the most promise. 


17. Psoriasis. Synonyms: Lepra vulgaris ; Lepra 


INFLAMMATORY AFFECTIONS. 195 


Willani ; Alphos,; Dry or Scaly tetter. Psoriasis is 
a non-contagious affection of the skin, exhibiting 
slightly elevated, reddened patches, of varying size 
and shape, generally circular, covered witha greater 
or less quantity of dry white scales, heaped together, 
and having a peculiar, shiny, bran-like appearance 
when removed. Beneath the scales there is found, 
on scraping, a little pellicle which comes off in a 
sheet, and is soft and pliable; the reddened sur- 
face beneath this may be made to bleed very 
readily. 

The amount and degree of eruption in psoriasis 
may vary greatly with the case, from a very few 
small patches, perhaps not covering in all one square 
inch, to an eruption affecting the larger share of the 
entire integument. The eruption selects by prefer- 
ence the extensor aspects of the limbs, and will gen- 
erally be found upon the elbows or-the front of the 
lower limbs; the scalp and top of the forehead, also 
- the loins, are favorite seats of psoriasis. Certain 
other portions are rarely affected, as the genital 
region, backs of the hands and feet, and face; while 
the palms and soles are almost never attacked, it 
may be said, never, without a development of the 
eruption elsewhere. 

Various designations have been given to the dif- 
ferent appearances which the eruption of psoriasis 
presents, all based upon the mode of development 
of the lesions. The first appearance is alwaysin the 


196 MANUAL OF DISEASES OF THE SKIN. 


form of aminute red spot (psorzasis punctata), which 
speedily becomes covered with a white scale, looking 
as if mortar had been spattered on ( psoriasis guttata). 
The tendency is always to increase in size peri- 
pherally, and when a little larger (psoriasis nummu- 
laris) there is a fancied resemblance of the round 
spots to coins; as the patches also tend to clear in 
the center, a ring-like appearance results ( psoriasis 
orbicularis or circinata). ‘In certain cases these 
rings may coalesce, and so clear up in portions as to 
produce gyrate forms (psorzasts gyrata); when large 
surfaces are involved the name psoriasis diffusa or 
aggregata has been used, and psoriasts inveterata is 
applied to express obstinacy. All these represent 
the same eruption in various forms. 

The term /epra was formerly applied to the erup- 
tion when forming the larger patches seen in psoriasis 
nummularis and orbicularis, the most typical forms of 
the eruption; at present the term lepra is used to 
designate leprosy, elephantiasis Gracorum, an en- 
tirely different affection, with which this has noth- 
ing in common. Willan applied the term psoriasis 
also to many conditions now recognized to be forms 
of eczema; these two diseases are to be entirely 
separated, eczema does not become psoriasis when 
a scaly stage is reached, although occasionally the 
two may be combined, and sometimes the one may 
develop into the other. 

Psoriasis presents quite different aspects as it oc- 


INFLAMMATORY AFFECTIONS. 197 


curs in strumous or gouty persons; in the former 
the scales are thick and apt to become heaped up, 
and the base is less congested, while in gouty sub- 
jects the scales are thin, often scanty, and the base 
is very red; the former itch but little, the latter may 
prove very troublesome from this symptom. The 
strumous cases are generally seen in children.and 
young persons, and yield more readily to cod-liver 
oil; in the gouty cases, which are rebellious, alka- 
lies, colchicum, and arsenic are most useful. 
Diagnosis.—Psoriasis may be mistaken for eczema, 
favus, lichen planus, lupus erythematosus, pityriasts cap- 
atis, seborrhea, syphilis, tinea trichophytina, and xero- 
derma, generally, sufficient care will suffice to de- 
monstrate features which are quite typical in every 
case of psoriasis. Upon the scalp the diagnosis 
from squamous eczema may be difficult, and certain 
cases of scaly syphilis resemble it very closely. 
Etiology.—Little or nothing is known of the actual 
causes of psoriasis: it has no connection with syph- 
ilis, or leprosy, it is not contagious, and no single 
article of diet, nor any local cause will produce it. 
It is met with about equally in males and females, 
seldom appears before puberty, although children 
may be affected, and very rarely develops for the 
first time after forty years of age. Very many 
psoriasis patients appear to be in perfect health, but 
in most of them faulty assimilation and disintegra- 
tion can be made out. 


198 MANUAL OF DISEASES OF THE SKIN. 7 


Treatment.—This is often very unsatisfactory, the 
eruption proving most rebellious, and recurring 
again and again, even in the face of energetic meas- 
ures. Internal treatment is necessary, as wéll as 
local, for the eruption will pretty certainly return if 
removed by local means alone. 

The strumous cases, as stated, do best under tonics 
and cod-liver oil given freely. Gouty cases require 
alkalies, which need to be administered with a free 
hand, while at the same time or later, arsenic, 
strychnia, and other tonics are required. The best 
alkalies are the acetate and bi-carbonate of potas- 
sium, and liquor potasse, combined with bitter - 
tonics (Formule 53, 54, 57, 59); the mineral waters 
do not seem to act as well as these. Later,.arsenic 
is of service; but in the more acute and itchy condi- 
tions it will often aggravate the eruption. 

Local treatment will sometimes be followed by 
most excellent results, and at other times will pro- 
duce almost no impression upon the eruption; it is 
very questionable if local measures alone have ever 
been followed by permanent cure. The agent hav- 
ing the most decided effect upon psoriasis is chryso- 
phanic acid, used in the form of ointment (Formula 
98). Under its use the spots will speedily become 
smooth and white, while the surrounding skin is 
stained of a purplish hue, deepening into mahogany 
color; if its use is discontinued too soon the spots 
will reappear; to be effectual it should be per- 


INFLAMMATORY AFFECTIONS. 199 


sisted in until the skin is evenly colored. But there 
are serious objections to it, from the staining of the 
skin and clothing, and the irritation often produced ; 
on delicate skins it will sometimes cause very con- 
siderable inflammation, and should always be em- 
ployed with caution at first; pyrogallic acid (For- 
mula 99) has been substituted for it with fair results, 
and does not stain so badly; it must be used with 
some caution, as serious systemic effects have been 
reported from its very free employment. Mer- 
curial ointments (Formule gI, 92, 93) rank very 
high, white precipitate being one of the best; sul- 
phur preparations also have considerable power 
over the eruption, and of these Vlemingkx solution 
(Formula 37) is most powerful, but often proves ir- 
ritating. Tar will often control the eruption, and 
may be employed in various ways, pure or in com- 
bination with other agents; the liquor picis alkali- 
nus, and the compound tincture of green soap (For- 
mulz 39, 40, 42) are very serviceable. 

To be effective local applications should be made 
directly to the diseased surface deprived of scales; 
for this purpose the patches are scrubbed or washed 
to free them, or alkaline baths are given (Formule 
I, 2, 3), after which the appropriate remedy is well 
rubbed into the affected parts. Mechanical removal 
of the scales, and even the scraping of the surfaces 
until they bleed, before the application, is sometimes 
followed by the best results. In more acute stages 


200 MANUAL OF DISEASES OF THE SKIN. 


and phases the eruption must be first treated by 
soothing measures, as described under eczema. 


18. Pityriasis capitis. Synonym: Alopecia fur- 
furacea. Several diseased states give rise to a scaly 
condition of the scalp, causing the so-called dandruff 
or dandriff, these are seborrhea, eczema, psoriasis, 
tinea tonsurans, and pityriasis capitis ; the scales 
which fall in these may be very much alike, but 
careful examination of the diseased surface will dif- 
ferentiate the conditions. 


Pityriasis capitis is an affection of the epithelial 
portions of the skin, exhibiting excessive growth 
and rapid exfoliation. The surface is seen to be 
white, and the scales are pearly; not only are they 
thrown off from the surface between the hairs, but 
the epithelial covering of the hair follicle takes part 
in the process, and the hair is seen to be surrounded 
by a small sheath of scaly formation, which will 
often be observed encircling the hair at any point, 
as it has slid on it after being detached. There is 
no moisture at any time, nor crusts; there is no red- 
ness of the base, nor thickening, nor itching, as in 
scaly eczema; nor are the scales greasy as in se- 
borrhcea. The nutrition of the hair remains fair, 
and the latter may be quite thick, although in time 
it falls; the annoyance is caused mainly by the 
mass of branny scales which dusts upon the cloth- 
ing at every movement. 


INFLAMMATORY AFFECTIONS. 201 


Treatment.—To be successful a thoroughly tonic 
internal treatment must be given, including careful 
attention to all the functions of the body; iron, ar- 
senic (Formule 52, 58, 59), cod-liver oil, and every 
means of improving the nutrition must be resorted 
to. Locally, occasional shampooing with soapy 
solutions (Formula 38) or washing with tar soap, 
followed by tannin ointment (Formula 87), and later 
by stimulating hair washes (Formule 49, 50, 51) can, 
with proper internal measures, entirely remove this 
annoying affection. 


VIII. PHLEGMONOUS ERUPTIONS. 


This group is characterized by localized inflam- 
matory action, resulting often in destruction of tis- 
sue and in the discharge of a slough of necrosed 
substance, the process being deeper than in the 
eruptions classed as pustular. Four affections are 
placed here, furunculus, anthrax, abscessus, and hor- 
deolum. 


I9. Furunculus. Boils or furunculi consist of 
circumscribed points of inflammation of the corium 
and connective tissue, terminating in suppuration 
and the formation of a central slough or core; when 
this escapes the little abscess tends to heal. Boils 
seldom come alone, but often in considerable num- 
bers, and frequently one will succeed another for a 
considerable period; the condition or state exhib- 
iting furunculi is known as furunculosts. 

g* 


202 . MANUAL OF DISEASES OF THE SKIN. 


Etiology.—The causes of boils are unknown, as far 
as any single element is concerned ; they are always 
indications of lowered vitality, although the impres- 
sion is very common that boils are salutary, and 
either indicate excess of health, or are in themselves 
healthful. The local cause can sometimes be found 
in local irritation, but often no adequate reason for 
their appearance can be discovered. 

Diagnosis—There are few conditions which can 
be mistaken for boils; ecthyma, and the large pustu- 
lar syphiloderm sometimes resemble them, but the 
hard, painful inflammation of a boil is charac- 
teristic; from carbuncle it is differentiated by its 
size. , 

Treatment.—This should always be directed to- 
wards rectifying general errors in nutrition; tonics 
are always called for (Formule 52, 55, 58, 59, 60), 
together with improved diet and hygiene. The 
preparations of sulphur have the most direct con- 
trol, and of these the most powerful is the sulphide 
of calcium, one-tenth to one quarter grain, from 
three to six times daily ; the hyposulphite of sodium 
is also efficacious. Locally, irritation should be care- 
fully avoided; such common remedies as soap and 
sugar to “draw” the boil, do harm and cause pain. 
Very much relief can be obtained from an ergot 
ointment, a drachm to the ounce, with a little oxide 
of zinc, applied both when forming and after rup- 
ture; when tense and hard, flaxseed meal poultices 


INFLAMMATORY AFFECTIONS. 203, 


are best, but if too long used they rather encourage 
the formation of new boils. 


20. Anthrax. A carbuncle is an inflammation of 
the skin and subcutaneous tissue, exhibiting dusky 
redness and brawny hardness, with deep, boring 
pain, and the subsequent formation of a large slough, 
with numerous sieve-like openings through the skin, 
discharging a small amount of pus; later the entire 
center sloughs out to a varying extent, leaving a 
granulating surface which heals with a scar. 

The most common location for a carbuncle is the 
back of the neck, but they may also be observed 
upon any portion of the body; it is always a serious 
affair, if of any size, and may prove fatal in those 
who are debilitated. The cause is unknown, other 
than such as produce furuncles. 

Diagnosts.—The red surface might be mistaken 
for erysipelas, but the hardness soon determines the 
diagnosis. 

Treatment.—Tonic treatment should be given 
from the outset, and the strength husbanded by the 
best of dietary and hygienic conditions, care being 
taken that the bowels and kidneys act rightly, 
especially in gouty subjects; stimulants, quinine, 
tincture of iron, etc., are all called for, and sufficient 
opium to secure rest at night. Sulphide of calcium 
given as for boils, has been effective in my hands in 
diminishing the suppuration. Locally most author- 
ities agree that benefit results from pressure, as with 


204 MANUAL OF DISEASES OF THE SKIN. 


lead plaster, early in the disease, while poultices are 
required: later ; the matter of poulticing can be over- 
done, and it should not be continued too long. 


21. Abscessus. Cutaneous abscesses are often 
seen on the face in connection with indurated acne, 
where large fluctuating collections of grumous pus 
are formed; they are also seen on the scalp of in- 
fants, especially in hot weather, and in connection 
with eczema. In the axillze the abscesses often 
appear to be wholly cutaneous, and such are prob- 
ably connected with the sweat-glands (hydro-adenitts). 

The ¢reatment is to be conducted on surgical 
principles, and often that suitable for eczema gives 
the best results. 


22. Hordeolum. Styes are closely related to 
boils, and consist of an inflammation in and around 
the meibomian glands, characterized by a painful 
swelling which rapidly suppurates, and disappears 
very quickly after the discharge of its contents; 
there generally is no central slough. Styes are very 
frequently associated with eczema and boils, and 
less commonly so with acne. They seldom come 
alone, but often in a succession, even of a dozen or 
more. They are always an indication of lowered 
vitality and disordered system; the principles of 
treatment applicable to eczema and boils are of 
most service. 7 


INFLAMMATORY AFFECTIONS. 205 


IX. ULCERATIVE AFFECTIONS. 


Ulcers are very generally secondary lesions, the 
result of some previous pathological process, as in 
the case of epithelioma, those connected with syph- 
ilis, etc., and are properly considered and classified 
in connection with the diseases to which they be- 
long. There are, however, several ulcerative lesions 
which are primary, such as ulcerative onychia, and 
simple ulcer of the leg, and the chancroidal ulcer ; 
the chancre, the primary lesion of syphilis, belongs 
to and is considered in connection with that dis- 
ease. 


23. Onychia. Many conditions affect the growth 
of the nail, such as eczema, psoriasis, and pityriasis 
rubra, and in syphilis there may be inflammatory or 
other disease from new deposit around or near the 
nail; ring-worm and favus also attack the nails, 
rendering them brittle (onycho-mycosts ). 

True onychia is most commonly of traumatic or- 
igin, as in ingrowing toe-nail, or sometimes results 
from occupation ; it is characterized by a suppura- 
ative inflammation of the tissues at the root of and 
around the nail, which may proceed to considerable 
ulceration, especially in strumous subjects, if not 
properly treated. When fully developed the tissues 
around are infiltrated and the nail seems sunk ina 
mass of fungoid granulations. 

Diagnosis.—It is very important to distinguish 


206 MANUAL OF DISEASES OF THE SKIN. 


syphilitic onychia from the non-specific form; other 
than this there is no difficulty in diagnosis. 
Treatment.—External irritation must be removed ; 
when a badly fitting shoe is the cause, cure is impos- 
sible without a change. Soothing and astringent 
treatment generally suffices to remove the difficulty ; 
an ointment of the liquor ferri subsulphatis, a 
drachm to the ounce, acts well, applied thickly 
after soaking the part in very hot water. Stru- 
mous onychia yields fairly to the application of 
powdered iodoform. | 


24. Ulcus. Two kinds of ulcers are here recog- 
nized, ulcus simplex, or simple ulcer, and ulcus vene-, 
vum, the venereal ulcer or chancroid. 

SIMPLE ULCER.—This is best typified in varicose 
ulceration of the lower leg. When fully formed this 
exhibits a painful, red, ulcerating surface, with hard, 
brawny and everted edges; it tends to bleed easily 
and gives rise to only a moderate, sanious exuda- 
tion, quite different from the purulent, fetid dis- 
charge from syphilitic ulcerations. Varicose ulcers 
are very commonly associated with more or less ec- 

_zema, both being due to the same causes; they are 
more apt to be single than those of syphilis, are 
more commonly found on the lower portion and 
anterior surface of the leg, whereas in syphilis they 
generally exist on the sides and back of the calf, 
also on the upper third, and often about the knee. 


INFLAMMATORY AFFECTIONS. 207 


Ulcers may form on any portion of the body, from 
injury, and as bed sores may give much trouble. 

VENEREAL ULCER, OR CHANCROID.—This is en- 

tirely distinct from the initial lesion of syphilis, or 
the chancre, and is a local sore produced by inocu- 
lation with a contagion whose nature is unknown: 
inflammation is commonly excited in neighboring 
glands producing bubo, but the system is never in- 
fected by the chancroid. The forms which the ulcer 
takes are various, but its main features are the fol- 
lowing: 1. Its brief incubation, it.appearing almost 
immediately after inoculation ; 2. Its copious, puru- 
lent secretion, which is anto-inoculable; 3. Its soft, 
ulcerated red base, with sharply cut and often un- 
dermined edges; 4. Its generally multiple character 
and tendency to spread; and, 5. The inflammatory 
engorgement of neighboring glands, with the tend- 
ency of the swelling to become red, painful, and to 
suppurate. vie 

Diagnosis.—It is often very difficult to differen- 
tiate chancroid from the ¢rue chancre, and often herpes 
progenttalis and balanitis will simulate it closely; 
eczema, psoriasis, lichen planus, and scabies may also 
affect the penis. 

Treatment.—Ulcers of the leg are best treated by 
the rubber bandage, as directed for eczema; very 
commonly constipation and defective urinary excre- 
tion exists, which must also be remedied. Varicose 
ulcers are most frequently found in those who stand 


’ 


208 MANTUAL (OF (DISEASES ‘(OF THE SKIN. 


a great deal, as in cooks, laundresses, bakers, bar- 
tenders, and car-drivers, and are rarely seen in those 
who walk, even though they remain long on their 
feet, as postmen. The therapeutic hint from this is 
that the more that walking can be encouraged, if at 
all well borne, the more quickly and permanently 
will the ulcers be healed; this is especially true 
while wearing the rubber bandage, by means of 
which patients, who before were almost helpless 
from painful ulcers, can often walk long distances. 
Strapping with adhesive plaster also answers fairly, 
and mildly stimulating and astringent ointments 
(Formule 94, 95,97) are of service insome cases. The 
treatment of the venereal ulcer relates to destroying 
the poison and modifying the diseased action; nitrate 
of silver is almost useless for this purpose, and the 
stronger acids, sulphuric or nitric, or the actual cau- 
tery are effective, with subsequent dressings of 
finely powdered iodoform or solutions of carbolic 
acid or zinc. 


- 


GIA P hE he avl: 


CLASS V. HEMORRHAGILZ.—HEMORRHAGIC AFFEC- 
TIONS. 


THREE diseases are here grouped, purpura, hemat- 
zdrosis, and scorbutus, all characterized by the escape 
of blood from the capillaries of the skin. 


- 1. Purpura. Synonyms: Land scurvy; Purples. 
Three varieties of this disease are recognized, pur- 
pura simplex, p. rheumatica, and p. hemorrhagica, all 
exhibit hemorrhagic patches of various sizes and 
shapes, slightly raised or level with the skin, which 
do not disappear upon pressure; appearing first of 
an almost arterial red, they quickly deepen in color, 
until, before they have entirely disappeared, they 
have passed through various changes, from purple 
to greenish brown, and yellow. 

PURPURA SIMPLEX.—This is commonly seen first 
upon the lower limbs, and also upon the forearms; 
the eruption usually develops symmetrically, and ‘is 
prolonged by successive crops. There are few con- 
stitutional symptoms, though the patient generally 
feels languid. Purpurasometimes occurs during the 
‘ administration of iodide of potassium. 

209 


— 


210 MANUAL OF DISEASES OF THE SKIN. 


PURPURA RHEUMATICA, or peliosis rheumatica 
resembles erythema multiforme almost more 
than purpura. It is characterized by rheumatic 
pains, affecting principally the large joints, and the 
subsequent appearance of small, sharply defined 
macules, often first about the knees, which are found 
to be hemorrhagic, and not to disappear on pressure. 

PURPURA HEMORRHAGICA.— This is a severe affec- 
tion exhibiting hemorrhages from various mucous 
surfaces as well as in the skin. There is prostration 
and the sudden appearance of hemorrhagic spots of 
varying size, often quite large and purplish, not dis- 
appearing on pressure. 

Diagnosis.—Purpura may resemble eczema, eryth- 
ema multiforme and nodosum, and ‘syphilis; the 
hemorrhagic variety may be mistaken for scorbutus, 
and hemorrhagic small pox, often wrongly called pur- 
pura vartolosa and black measles. 

Prognosts.—Purpura simplex is generally a mild 
affair, and yields well to treatment; purpura rheu- 
matica is much more obstinate; purpura hemor- 
rhagica is not unfrequently fatal. 

Treatment.—Ergot is the chief remedy of service 
in purpura, although quinine in free doses is most 
effective in the rheumatic form; ergot should be 
given boldly, and if necessary by hypodermic injec- 
tion. -Tonic treatment is also indicated. 


2. Hematidrosis. Synonyms: Ephidrosis cruen- 


HEMORRHAGIC AFFECTIONS. 211 


ta, Bloody sweat. This is a very rare condition, 
characterized by the escape of blood through the 
sweat glands; the fluid which exudes may be very 
watery. It is most frequently seen in hysterical 
girls with faulty menstruation. 

Treatment.—This must be directed against the 
conditions present; in addition, ergot should be 
given in doses sufficient to arrest the hemorrhage. 


3. Scorbutus. Synonym: Scurvy. This is a 
constitutional state of exhaustion, during which 
hemorrhagic, bruise-like ecchymoses occur upon the 
skin, generally of some size, together with a spongy 
state of the gums and subsequent loosening of the 
teeth ; it is dueto adeficiency of fresh vegetable food 
in the dietary, and if unchecked tends to death. 
There is a leaden color to the skin, malaise and 
rheumatic pains, and cedema. 

Treatment.—The treatment is almost wholly diet- 
ary; an abundant supply of fresh vegetables and 
lime-juice is generally all that is required ; tonics are 
of service later. 


GHAR heey 11: 


CLASS VI. HYPERTROPHIA.—HYPERTROPHIC AF- 
FECTIONS. 


THESE are characterized by an augmentation of 
some of the normal elements of-the skin, and are 
grouped under five heads: Hypertrophy, A, of pig- 
ment; B, of epidermis and papille ; C, of connective 
tissue; D, of hair; E, of nail. 


A. HYPERTROPHIES OF PIGMENT. 


In this group are found five distinct states: en- 
tigo, chloasma, melanoderma, morbus Addisonit, and 
nevus pigmentosus; all exhibit hypertrophy of pig- 
ment, deposited in varying degree and manner in 
the deeper cells of the rete malpighii. Their treat- 
ment will be considered together. 


I. Lentigo. Synonym: freckles. This well 
known deformity consists of deposits of pigment of 
small size, of a yellowish or brownish color, scat- 
tered mainly over the exposed portions of the skin. 
‘They are most common in those having light com- 
plexions, especially persons with red hair; they 

212 


HYPERTROPHIC AFFECTIONS. 213° 


may affect other regions besides those exposed to 
sunlight. 


2. Chloasma. Synonym: Liver spots ; Moth. This 
consists of yellowish brown, pigmentary discolora- 
tions of various sizes, situated chiefly about the face 
and neck ; it is most commonly seen in females, but 
occurs also rarely in males. The surface is smooth 
and not scaly, unless irritated, and the margins of the 
patches are quite sharply defined; the forehead and 
temples are common localities, also about the mouth. 
The cause in females is frequently uterine or ovarian 
disease (chloasma uterinum), though it is quite prob- 
able that liver disorder is also an important ele- 
ment. / 

Diagnosis.—It may be mistaken for ¢zxea versicolor, 
also for the pzgmentary syphilide and leucoderma. 


3. Melanoderma. This relates to various brown 
discolorations, which may occur from different 
causes, some local, others constitutional. The ef- 
fects of the sun are to produce a general darkening 
of the skin termed ephelis, sunburn, or tan; irritat- 
ing agents as blisters often leave behind them a 
considerable discoloration of the integument. Long 
continued cutaneous congestion and inflammation 
results in pigmentary deposits, as is observed after 
eczema of the lower extremities, in old cases of 
phthiriasis, and after many syphilitic lesions. 


214 MANUAL OF DISEASES OF THE SKIN. 


Again, pregnancy induces a discoloration about 
the nipples ; cancer causes a general pigmentation, 
as also melanotic sarcoma, leprosy, scleroderma, etc. 
A. mechanical discoloration of a peculiar leaden or 
bluish color, is brought about by the long continued 
internal administration of nitrate of silver, which 
has received the name of avgyrza. The most re- 
markable general discoloration of the skin is that 
connected with disease of the supra-renal capsules, 
which is such a constant feature in this complaint as 
to receive a separate name, well recognized, as next 
described. 


4. Morbus Addisonii. Synonyms: Sronzed-skin 
disease ; Supra-renal melasma. The curious anez- 
mic and cachectic state described by Addison as 
connected with disease of the supra-renal capsules, 
has often, as its first symptom to excite serious at- 
tention, a peculiar bronzing of the skin; this pre- 
sents ‘‘a dingy or smoky appearance, or various 
tints or shades of deep amber or chestnut brown, 
most strongly manifested on the face, neck, superior 
extremities, penis and scrotum, and in the flexures 
of the axilla and around the navel.” 

Diagnosis—The only conditions which could be 
mistaken for this are a general efhelis or tanning, 
chloasma, leucoderma, pigmentary syphilis, and tinea 
versicolor. 


5. Nevus pigmentosus. Synonym: /igment- 


HIVPERTROPHIC AFFECTIONS. . 215 


ary mole. ‘This consists of a pigmentary deposit of 
varying size, color, and shape, often of congenital 
origin, but occasionally developing at any period; 
generally there, are several of these deformities. 
This form of nzvus may exist alone, or be combined 
with hypertrophy of other elements; the epidermis 
and papillary layer are often involved, and a rough, 
warty condition results (~@vus verrucosus). When 
hair grows as well, ittakes the name of nevus p1- 
losus, to be described later. 


Treatment of hypertrophties of pigment.—The loca- 
tion of the coloring matter deposited in all the 
lesions described is beneath the epidermis, either in 
the rete malpighii, where pigment is found normally, 
or still deeper. It is difficult, therefore, to remove 
it by superficial applications, which destroy the life 
of the cuticle only; if attempted by agents which at- 
tack deeper tissues, ascar may result. If effected at 
all it must be by measures which modify the nutri- 
tion and cause the absorption of the pigment, or by 
repeated removal of the epidermis by such means 
will induce the newly formed cells to have less 
coloring matter. 

These deformities are, therefore, unsatisfactory to 
treat ; the best means are lotions containing bi-chlo- 
ride of mercury (Formula 45), and if their action is 
too strong it can be modified by an ointment (For- 
mula g1). Freckles sometimes yield to these appli- 


216 MANUAL OF DISEASES OF THE SKIN. 


cations, but are often rebellious ; chloasma can usu- 
ally be thus removed, but is apt to return with a 
continuance of liver or sexual derangement. But 
little can be done for the forms of melanoderma; the 
discoloration accompanying Addison’s disease is 
irremediable; pigmentary moles may be excised or 
destroyed with strong potassa solutions. 


B. HYPERTROPHIES OF EPIDERMIS AND PAPILLA. 


Six conditions of disease are recognized as be- 
longing to this group, zchthyosis, keratosis pilarts, 
cornu cutaneum, clavus, tylosis, and verruca. 


1. Ichthyosis. Synonym: fsh-skin disease. 
This, as the name signifies, is characterized by a 
dry, hard, scaly condition of the skin to a greater or 
less extent, which in marked cases may assume an 
appearance suggestive of the scales of a fish; in 
severe degrees the papillary layer takes part in the 
process and may be very considerably hypertrophied. 

Most commonly ichthyosis is a congenital disease, 
several cases often occurring in a family, which, while 
manifesting but a slight degree of alteration during 
the first years, may increase greatly during child- 
hood. The eruption is always most developed on 
the extensor surfaces of the body, especially on the 
elbows and knees, the flexor surfaces of these joints 
being spared, however greatly the disease is de- 
veloped. In milder degrees it has the name #xero- 


YHVPERZROPHICAPFECTIONS. 20 


derma, dry or parched skin; ichthyosis patients sel- 
dom perspire much, and the integument may be so 
dry and harsh as to crack and cause great pain. Two 
degrees or forms of the affection are recognized, 
ichthyosis simplex and ichthyosis hystrix. 

ICHTHYOSIS SIMPLEX represents the milder de: 
grees, where the hypertrophy appears confined to 
the epidermis; the scales are not thick, and may be 
laid out ina strikingly regular form, showing the 
deepest fissures in lines of motion. 

ICHTHYOSIS HYSTRIX.—Under this name have 
been described cases presenting a great hyper- 
trophy of papille with heaped up masses of epi- 
dermal tissue; this may occur over a considerable 
extent, or appear in localized patches, sometimes 
following nerve tracts. Different cases present very 
different grades of the disease, from a few groups 
of brownish yellow, wart-like excrescences, to large 
areas of almost horny productions, sometimes of 
deep color (forcupine men). 

Diagnosis.—Milder cases resemble squamous ecze- 
ma, pityriasis rubra, and possibly psorzaszs ; but all 
these have redness of skin, while ichthyosis is char- 
acterized by the leaden paleness of the integument. 

Prognosts.—The condition is well-nigh incurable, 
but very great relief and benefit can be obtained by 
proper treatment. Young subjects should be per- 
sistently and actively treated when the disease is 
developing, as affording the best hope of escaping 


Io 


r 


218 MANUAL OF DISEASES OF THE SKIN. 


further trouble. In very severe cases, the pain and 
even deformity may be very great. 

Treatment.—The very free internal and external 
use of oily preparations, as linseed and cod-liver oils, 
yields the best results, together with frequent alka- 
line baths (Formule 1, 2, 3). 


2. Keratosis pilaris. Synonyms: Lichen pilaris,; 
Pityriasis pilaris. ‘This is characterized by the ap- 
pearance of minute, pointed, epidermal elevations 
about the orifices of hair follicles. The localities 
most commonly affected are the thighs and backs of 
the upper arms, but any portion may present the 
eruption. In three cases I have seen it affecting 
the hair follicles of the scalp, in one of these the 
eruption was also very general. 

Treatment.—TVhe epidermic mis-growth is best 
treated by alkaline baths (Formule 1, 2, 3), or the 
free use of ordinary baths and soap, with the subse- 
quent inunction of oily matter, such as cod-liver and 
linseed oil, and mild mercurial ointment (Formule 


94, 96). 


3. Cornu cutaneum. Synonyms: Cutaneous 
horn; Cornu humanum, Horny excrescence. Cutaneous 
horns in structure resemble very closely the ordi- 
nary horns observed on the lower animals; they are 
usually of small size, but have been observed six 
inches in length. They are also of varying thick- 


HVPERTROPHIC AFFECTIONS. 219. 


ness, and rather abruptly conical. Human horns 
commonly develop on the head, from any portion 
of the face, but have also been noted in various por- 
tions of the body, and in a number of instances on 
the penis. 

Treatment.—lf a horn is torn off it regrows, unless 
the base is destroyed; it is necessary, therefore, 
either to excise the entire structure with its base, 
or to destroy the latter very thoroughly with a deep 
acting caustic, as the chloride of zinc or Marsden’s 
arsenical paste (Formulz Io, 14). 


4. Clavus. A corn is a localized hypertrophy of 
the epidermis, in the form of a small, rounded mass, 
horny to the feel, projecting slightly from the skin; 
its base is conical, reaching down even upon and 
into the true skin, which may atrophy by the pres- 
sure occasioned. Two varieties of corns are spoken 
of; the “ard corn when seated on an outer surface, 
and the soft corn, located between the toes, where the 
parts are kept moist. Both are essentially the same, 
and both are due almost invariably to wrongly fit- 
ting coverings for the feet; both may give rise to 
serious inconvenience from the darting pains which 
occur when pressed upon, or even spontaneously. 

Treatment.—The first step is to secure a properly 
fitting shoe, for without this the condition will re- 
cur in the same or another situation: often it is 
necessary to have special lasts made, but ‘it also 


220 MANUAL OF DISEASES OF THE SKIN. 


may suffice to wear different pairs of shoes on alter- 
nate days, that the pressure may come in other 
places. The ringed protective plasters in common 
use answer to keep off the pressure in a measure. 
To remove the corn, soaking with hot water, or a 
poultice over night will soften the part and admit of 
its being dug or picked out with little pain. The 
corn plasters contain various softening agents, such 
as carbonate of potash and acetic acid; most of 
them are probably harmless, and often ineffectual. 
Cutting or rasping frequently suffices, if attention be 
paid to the foot covering. Soft corns yield to care- 
ful separation of the toes with picked cotton and 
oxide of zinc or tannin ointment, with occasional 
touching with nitrate of silver, and the relief of 
pressure by properly fitting shoes. 


5. Tylosis. Synonyms: Zyloma ; Callositas ; Cal- 
lus ; Callosity. ‘This consists of an abnormal de- 
posit of epidermal cells, forming yellowish or gray- 
ish horny masses of varying size and thickness, oc- 
curring especially on parts exposed to pressure or 
friction; this condition is an augmentation of that 
normally found on the soles and palms, and may at 
times give much annoyance. It differs from clavus 
or corn in its diffuse character, the absence of pain 
except when cracked, and its involving only the 
outer portions of the epidermis. In rare cases the 
entire palms and soles may become the seat of this 


HYPERTROPHIC AFFECTIONS. PPG | 


alteration, and they become thickened and stiff, 
without any known cause, certainly not from press- 
ure or friction. 

Lreatment.—No means of cure are known other 
than mechanically removing the superfluous matter 
by a knife or rasping. When the soles become 
greatly hardened from standing, and are fissured and 
painful, great benefit can be obtained by wearing’ 
oiled silk cut a little larger than the sole, within the 
stockings, day and night. 


6. Verruca. A wart consists of a circumscribed 
papillary hypertrophy, with more or less epidermal 
accumulation : it may vary greatly in size and shape, 
quite different conditions presenting themselves in 
different situations, Four varieties may be made 
out, verruca vulgaris, v. senilis, v. necrogenica, and v. 
acuminata. 

VERRUCA VULGARIS.—Common warts are hard, at 
times almost horny excresences, usually flat on the 
surface, which is marked by fissures representing the 
spaces between the hypertrophied papilla. The up- 
per portion may be pared down, but at a certain 
point the bleeding papillz are reached, with the 
epidermal prolongations between them : the seeds of 
warts are the hypertrophied epidermis masses pro- 
jecting down between the enlarged papille. 

VERRUCA SENILIS.—This refers to the multiple, 
flat, dark yellow or brown, slightly horny elevations, 


222 MANUAL OF DISEASES OF THE SKIN. 


seen especially about the face, shoulders, and arms 
of elderly persons. 

VERRUCA NECROGENICA. — Peculiar, indolent, 
warty growths, red at their base, and moderately 
-elevated, sometimes occur upon the hands as the 
result of dissection wounds; they are very obstinate, 
and occasionally almost disappear in one place, and 
regrow near by, or again on the former site. 

VERRUCA ACUMINATA.—This constitutes the so- 
called venereal wart, or vegetations; it is also known 
as the pointed condyloma, spitze condylom of the Ger- 
mans, to distinguish it from the droad or flat condy- 
loma of syphilis, with which it has no relation, the 
latter being a mucous patch, mucous tubercle, or syphi- 
litic papule ina situation where it is kept continuously 
moist. Venereal warts occur commonly about the 
genital and anal regions, and exhibit clusters of 
papillary growths, generally pointed on the extrem- 
ity, red and succulent, and often bathed in a puru- 
lent secretion; they sometimes attain ‘great size. 
They are not, strictly speaking venereal, for although 
the acrid secretions of gonorrhcea and chancroid favor, 
their growth, they are often found entirely dis- 
tinct from any possible venereal cause, and are ob- 
served on other portions of the body than the geni- 
tal region. 

Treatment.—Common warts often disappear spon- 
taneously; they may also be removed very conveni- 
ently and satisfactorily by means of the curette or 


HVPERTROPHIC AFFECTIONS. 223 


sharp spoon. Caustics of various kinds may be used, 
after paring down the wart, care being taken not to 
cause too much destruction. They disappear slowly 
under the application of diluted acetic acid, applied 
morning and night; equal parts of tincture of iron 
and diluted muriatic acid are also effective. Arsenic 
internally also, is sometimes followed by their dis- 
appearance. Venereal warts, when small, may be 
snipped off and the base cauterized with glacial acetic 
or strong nitric acid; when large they will shrivel 
under the per-sulphate of iron, also under the tinc- 
ture of thuja occidentalis, and may then be removed 
by the knife, sharp spoon, or ligature. 


C. HYPERTROPHIES OF CONNECTIVE TISSUE. 


Six names appear in this division, scleroderma, 
morphea, sclerema neonatorum, elephantiasis (Ara- 
bum), dermatolysis, and frambesia. 


1. Scleroderma. Synonyms: Scleriasts ; Scler- 
ema, Dermatosclerosis; Hide-bound skin. Asthe name 
signifies, this is characterized by a hard, sole-leather 
like condition of the skin of a greater or less extent, 
which may occasion much discomfort by its rigid, 
tense, and immovable state, and even pain by its 
tendency to contract. In some instances the altera- 
tion is limited in extent, asin a band along or around 
a limb or on the body; or again the disease may be 


¢ 


224 MANUAL OF DISEASES. OF THE SKIN, 


more general, and involve the entire trunk, and 
cause great distress by interfering with respiration. 

Generally the disease commences insidiously, and 
the hardening is the first feature noticed ; in rare 
cases, and when more general, it may be preceded 
by chilly feelings and pains, or a numb sensation in 
the part. When well developed, the skin is of a 
brownish yellow, waxy look, generally on a level 
with the surrounding integument, with or without 
slight scaling, and so stiff, hard, and board-like, that 
it cannot be pinched up or slid upon the tissues be- 
neath. 

Ettology.—This is entirely unknown; the disease, 
which is very rare, occurs far more frequently in fe- 
males than males. 

Diagnosis.—The only condition which much re- 
sembles this is szorphewa, which by some is consid- 
ered to be the same affection, more localized ; dif- 
fused cancer, especially of the trunk, cancer en cuir- 
asse, may also be mistaken for scleroderma in this 
region. Some cases of eczema of the palm present a 
hard condition, which has been wrongly called scler- 
oderma at times, with which it has no connection 
whatever. 

Treatment.—Very little can be accomplished by 
internal medication ; tonics and oily substances are 
most indicated. Locally, electricity has been found 
of service, and this, with stimulating inunctions, of- 
fers the best prospect of improvement. The disease 


HYPERTROPHIC AFFECTIONS. 225 


sometimes disappears spontaneously; often it re 
mains for a long period stationary, and sometimes 
it progresses rapidly until even great areas are in- 
volved. 


2. Morpheea. The features of the diseased skin in 
morphcea resemble those of scleroderma, in the hard, 
lardaceous character of the affected portion, and the 
impossibility of pinching it up, and in its dirty, yel- 
lowish color. But it differs from that disease in the 
limited extent and commonly roundish shape of the 
patches, which are surrounded by a pinkish, conges- 
tive border or halo; their outline is often very sharply 
defined, so that their edge can be detected by pal- 
pation with the eyes shut; this contrasts strongly 
with the indefinite outline of scleroderma, which 
merges insensibly into the healthy skin. 

Writers are by no means agreed upon all the 
characteristics of morphcea, as sometimes cases pre- 
sent very peculiar phenomena; the process which in 
its earlier and more characteristic phases exhibits 
the elements of hypertrophy, and the infiltrated, 
leather-like skin, may at a later stage show atrophy, 
although at times resolution takes place, leaving 
healthy skin. The disease is pretty certainly of 
neurotic origin, and it is probable that the condition 
known as hemtiatrophia factalts is closely related to 
that under consideration, if not identical with it. 


Diagnosis.—The only lesion liable to be con- 
10* 


226 


MANUAL OF DISEASES OF THE SKIN. 


founded with morpheea is scleroderma, from which it 
is differentiated by the features given in the accom- 


panying table. 


The so-called morphcea patches of 


leprosy have nothing to do with this disease, but are 
only one phase of its skin lesion. 


MORPHCA, 


Beginning.— Generally from a 
purplish congestive spot ; new 

ones being often observed in 
the neighborhood. 


Margin.—Sharply defined and 
generally bordered by a con- 
gestive halo. 


Lxtent.—Generally small and cir- 
cular; and extended patch is 
generally composed of several 
others. 

Condition.— Tolerably movable ; 
hardness rather waxy. 


Color.—Pretty uniformly of a 
tawny yellow, old ivory color. 


Tendency. — Often disappears 
spontaneously, or if remaining, 
generally causes little inconven- 
ience; seldom, if ever, contracts. 


Duration.—Increases rather rap- 
idly and sometimes disappears 
in a few months, 


SCLERODERMA. 


Begins insensibly over considera- 
ble areas, the hardening being 
the first change observable. 


Illy defined edge merging insensi- 
bly into healthy skin ; no con- 
gestive halo. 


Generally greater expanse af- 
fected and the neighboring 
parts involved by extension. 


Firm and immovable: harden- 
ing more diffuse. 


Apt to be irregularly pigmented. 


Exceedingly persistent, with a 
tendency to increase and to 
cause distress by contraction. 


Generally increases slowly, and 
may remain for years, or until 
death from intercurrent disease. 


HVPEREROPAIC AFFECTION S. O27 


Treatment.—Very little can be said in regard to 
this ; tonics, and especially arsenic long persisted in, 
are of most value, with electricity locally, and mer- 
-curial inunctions. 


3. Sclerema neonatorum. This very rare affec- 
tion occurs soon after birth, and is generally fatal. 
It commences with an cedematous infiltration, the 
skin being hard, tense, and of yellowish, brownish, or 
even a livid purple hue; it is generally observed 
first upon the feet or calves, and extends rapidly 
upwards. There are with the stiffened skin, pain, 
convulsive movements, scanty urine and failing 
strength, and the child generally dies with some af- 
fection of the lungs. 

Treatment.—This has generally proved unsuccess- 
ful. External warmth, by baths and other means, 
with inunctions, together with stimulants, offer the 
best prospects. 


4. Elephantiasis (Arabum). Synonyms: Pachy- 
dermia ,; Bucnemta tropica,;, Elephant leg; Barba- 
does leg. This ‘disease is to be entirely disasso- 
ciated from elephantiasis Grzecorum, which is now 
known as lepra or leprosy. It is characterized 
by an hypertrophic thickening of the skin and subcu- 
taneous tissue, with cedema and subsequent papil- 
lary hypertrophy; the most common seat of the 
disease is one lower extremity, rarely both; next 


228 MANUAL OF DISEASES OF THE SKIN. 


the genital parts, and rarely the upper extremities 
and breasts. The disease begins with repeated at- 
tacks of cutaneous inflammation like erysipelas, of 
greater or less severity, leaving some thickening 
after each accession, until, after a varying period, the 
part is found to be greatly increased in size, quite 
hard and more or less pigmented, and in older cases 
presenting papillary prominences and fissures; the 
swelling is found to be somewhat cedematous, 
but the amount of pitting on pressure may be very 
slight. 

Etiology.—The nature of the disease appears to 
be essentially connected with the lymphatics, which 
are greatly increased in size, and the mass of the 
disease consists of hypertrophied connective tissue. 
The affection is common in warm countries, but oc- 
casional cases are met with in every land: its true 
cause is unknown, but has been attributed by 
many to the presence of the filaria sanguinis, which 
has been found in the lymph exuded from the vesi- 
cles occurring in lymph scrotum, a condition which is 
believed by observers in the East to be identical with 
elephantiasis. The disease is most frequent between 
the ages of twenty-five and sixty, and is far more 
often seen in males than females, and especially 
among the poor. 

Diagnosts.—Certain cases of chronic eczema of the 
feet and legs, may exhibit such a thickening and 
papillary hypertrophy as to resemble elephantiasis ; 


cal 


HVPERTROPHIC AFFECTIONS. 229 


the swelling attendant upon phlegmasia dolens may 
also suggest this disease. 

Treatment.—When well developed, the rubber 
bandage affords the best results upon the legs; when 
the disease affects the genital parts, excision gives 
almost universally good results. In earlier stages, 
quinine in full doses is recommended, with diuret- 
ics and rest, together with cooling antiphlogistic 
measures. 


5. Dermatolysis. Synonym: Cutzs pendula. This 
consists of an hypertrophy of the connective tissue 
elements of theskin of any portion, to such an extent 
that it hangs in folds; this may be so slight as to 
cause little annoyance, or may increase to an exces- 
sive degree. Any region may be affected, and 
cases are reported where the condition had assumed 
monstrous proportions and very curious aspects. 
The causes of this freak of nature are unknown. 

Treatment.—Operation with the knife affords a 
satisfactory means of relief. 


6. Frambeesia. Synonyms: Yaws; Pian; En- 
demic verrugas. This is a disease almost wholly 
confined to tropical climates and principally seen 
among the colored races. It is characterized by the 
presence upon the skin of a papulo-pustular erup- 
tion, which ulcerates and is followed by exuberant 
granulations. ‘The skin remains unbroken until 


230 MANUAL OF DISEASES OF THE SKIN. 


the yaws attain, perhaps, the size of a small pea, 
but the cuticle may give way at any time. Then a 
yellowish, spongy surface presents itself, from which 
a thin fetid fluid oozes, and this spongy body con- 
tinues to enlarge, and projects considerably from 
' the surface. Yaws are usually circular in form, and 
may be seen in the same patient of all sizes, from 
that of scarcely more than a pin’s head to a patch 
of one or two inches in diameter, and in every stage 
of their progress. Generally they are separate, but 
sometimes in groups close together, small and great. 
Again they may be met with in oval form, but more 
rarely, in other cases they are irregular in shape, 
and so close together as to make one mass. It fre- 
quently happens that one of these tubercles as- 
sumes very large proportions, one or two inches in 
diameter, or even more, projecting from the skin, 
like the other yaws, covered with yellow scabs, or 
having a moist yellow surface, streaked with red.” 
£:tiology.— The disease is one of filth, and is prop- 
agated by contagion. Its real nature is unknown, 
and recent observers agree that it has no connection 
with syphilis. , 
Diagnosis.—It is most liable to be confounded 
with syphilis. Under certain circumstances exu- 
berant granulations appear in many diseased con- 
ditions, and to these the name frambcesia is some- 
times wrongly given ; its use should be restricted to 
the tropical disease here described. JZycosis is a 


HVPERTROPHIC AFFECTIONS. ope 


term which has been employed as a synonym for 
yaws ; this name is also used by the French, to rep- 
resent lymphadenoma, with the title mycoses fun- 
goide. 

Treatment.—Cleanliness, good food and hygiene, 
with tonics, usually arrest the disease ; locally, car- 
bolic acid lotion and weak nitrate of mercury oint- 
ment comprise the measures required. 


D. HYPERTROPHIES OF HAIR. 


Two hypertrophic conditions of hair are found 
here, Azrsuties and nevus pilosus , the former repre- 
sents excessive hairy growth, either of the entire 
body, or of parts nominally supplied with long hair, 
or in situations provided only with /axugo , the lat- 
ter refers to localized hypertrophy of hair, in patches, 
which generally exhibit, also, hypertrophy of pig- 
ment. 


1. Hirsuties. Synonyms: Polytrichia,; Hyper- 
trichosis, Trichauxis; Augmented hairy growth. 
Individuals vary greatly in the amount of hairy de- 
velopment, and various instances are on exhibition, 
from time to time, where the normal hair of the 
head or beard is augmented very greatly, or even 
where the entire body and limbs present an exces- 
sive growth. Medically, hypertrophy of hair is of 
special interest when it develops in unusual situa- 
tions, as on the face and arms of females, which it 


232 MANUAL OF DISEASES OF THE SKIN. 


may do to a varying degree, from a few straggling, 
stiff hairs on the chin or upper lip, to a completely 
bearded condition. 

Etiology —No satisfactory cause is established for 
the excessive growth of hair on the face of women, 
but frequently it occurs in those of masculine quali- 
ties, although in some of the most marked instances 
of those having a full beard quite the contrary is ob- 
served ; they have even been mothers of families. In 
a certain number of those thus affected, uterine or 
ovarian disease is present, and insanity has also been 
noticed in this connection. 

Treatment.—To be effectual the life of the follicle 
and the hair papilla must be destroyed ; consequent- 
ly, in the case of hairs of any length, the “ depilato- 
ries’ so largely advertised to permanently remove 
this condition, are not to berelied on. For the re- 
moval of finer hairy growths they may occasionally 
prove sufficient, but again they may stimulate them 
to greater hypertrophy. Depilatories are agents 
which soften and dissolve the hair in the same man- 
ner as, but to a greater degree than soap, when used 
for shaving ; they are put on as a paste, and left five 
to ten minutes on the skin and then scraped off. 

For hairs of larger growth and fewer in number, 
destruction of individual follicles is necessary. This 
can be accomplished by introducing a straight glov- 
er’s needle into each follicle, after the extraction of 
the hair, and rotating it several times, as first pro-. 


HYPERTROPHIC (AFFECTIONS: 233 


posed by the writer several years ago; the effect is 
heightened by dipping the needle in carbolic acid 
before insertion. More recently electricity has been 
employed with advantage for this purpose; the 
negative pole is attached to the needle, and the 
positive is held in the patient’s hand, a current from 
between six and twelve cells being employed; the 
current is to be completed by the patient touching 
the electrode in the hand after the needle is z sztz. 
The needle is introduced while the hair is yet in its 
follicle, and the electrolytic action loosens the hair 
with the formation of a foam around it, when it can 
be readily extracted. With either of these processes 
a certain proportion of hairs regrow. 


2. Nevus pilosus. Synonym: Hazry mole. With 
hypertrophy of hair in small localized patches there 
is generally a pigment deposit, and some little pa- 
pillary hypertrophy, whereby the surface is slightly 
raised. Hairy moles may be of various sizes and 
shapes, even to covering a portion of the face or body. 

Treatment.—Caustic potassa, in very strong solu- 
tion, carefully applied, will destroy the whole growth 
and leave a moderate scar; unless too large, excis- 
ion or thorough removal with a sharp spoon is to be 
preferred. 


E. HYPERTROPHIES OF NAILS. 


The nails become affected in many diseases, as 


234 MANUAL OF DISEASES OF THE SKIN. 


was briefly mentioned in connection with the sub- 
ject of onychia. As hypertrophy, two forms or con- 
ditions are observed, onychogryphosis and onychauxts. 


1. Onychogryphosis. This relatesto a thickened 
and more or less curved or twisted nail, as is not in- 
frequently observed upon the toes of elderly persons 
who have worn ill-fitting shoes. Some cases are on 
record where such nails had obtained a very great 
length and size. 


2. Onychauxis. Under this term are included 
anomalous conditions of nail, represented by the 
development of superfluous nails, and also the ex- 
cessive growth of a normal nail. Instances are re- 
corded of nails measuring several inches in length. 


CHARTER XVIII 
CLASS VII. ATROPHILA.—ATROPHIC AFFECTIONS. 


THIS class of diseases is characterized by an atro- 
phy of the elements of the skin and its appendages, 
and is subdivided into four groups relating to: 
Atrophy, A, of pigment; B, of corium; C, of hair; 
and D, of nail. 


A. ATROPHIES OF PIGMENT: 


Three disease states are placed here, namely: 
albinismus, leucoderma, and cantttes. 


1. Albinismus. Synonyms: Aldinism,; Leucas- 
mus universalis ; Congenital leucopathia. ‘This has 
reference to a congenital condition observed in cer- 
tain individuals who are called Albinos, in whom - 
there is an absence of pigmentary matter not only 
in the skin, but also in other portions of the body; 
the skin is of a milky white, the hairs everywhere 
are of a white or very light color, and the eyes have 
a peculiar pinkish or bright red color, and are very 
sensitive to light, owing to the absence of pigment 
in the choroid. 

Etiology—The cause of the anomaly is entirely 

235 


236 MANUAL OF DISEASES OF THE SKIN. 


unknown ; it is most common in the negro race, and 
in the same family some children may be very black 
and others perfect albinos. It also occurs partially 
in the negro as a congenital condition ; when devel- 
oping subsequently its condition belongs to that 
next described. 


2. Leucoderma. Synonyms: Vitiligo; Leuko- 
pathia acquisita; Cutis variegata; Acquired leucas- 
mus ; Piebald skin. This consists of an irregular dis- 
tribution of the pigment matter of the skin, whereby 
smooth, rounded, white patches of varying size and 
extent are produced, surrounded by an area in which 
the pigment is augmented. The surface is devoid 
of scales and on a level with the surrounding integu- 
ment, and there is no abnormal sensation experi- 
enced in the parts. Their most common location is 
upon the backs of the hands and fingers, and on the 
neck, though any region of the body, or a consider- 
able portion of it, may ultimately be affected ; these 
cases are often exhibited in museums as “spotted 
mei, 

Diagnosis.—It is to be distinguished from chlo- 
asma, tinea versicolor, and morphea. It has no con- 
nection with leprosy, although it has sometimes 
been described as whzte leprosy, nor has it any re- 
lations to syphilis, although the pzgmentary syphil- 
oderm may resemble it very closely. | 

Treatment——The condition is a very rebellious 


ATROPHIC AFFECTIONS. 237 


one; nerve tonics are mostly recommended, and I 
have seen a very marked benefit from the use of 
phosphide of zinc and nux vomica (Formula 71) 
taken internally; as the eruption sometimes varies 
spontaneously, the real value of this cannot be yet 
determined. Local applications of bi-chloride of 
mercury and ammonia (Formula 45) certainly bene- 
fit it greatly in many cases. 


3. Canities. Synonym: Grayness of the hair. 
The causes of the turning gray of the hair are en- 
tirely unknown; while it isa common sign of age, 
the period at which the hair changes varies very 
greatly in different individuals, and often appears to 
be a family peculiarity. In many instances prolonged 
grief and trouble cause it to whiten early, and un- 
doubted cases are on record where sudden fright or 
sorrow have caused the change to take place within 
a single day. It is not very uncommon to have 
tufts of gray hair over the track of nerves which 
have been the subject of neuralgia; the hair on 
patches of leucoderma is usually white. 

Although all signs point toward a nervous influ- 
ence in producing the change, but dittle can be ac- 
complished by treatment in the way of restoring the 
normal condition. 


B. ATROPHIES:- OF ‘THE ‘CORIUM:. 


Two affections are recognized here, atrophia cutis, 


238 MANUAL OF DISEASES OF THE SKIN. 


from idiopathic causes, occurring in various forms 
and conditions; and atrophia senzlis. 


1 Atrophia cutis. Atrophy of the skin may 
occur in three forms: first, as amore or less general 
condition such as occurs in connection with certain 
other disease states, and also following injury of 
nerves, the glossy skin of writers. Atrophy may ap- 
pear as a symptomatic condition in parts which have 
been greatly distended, as in the “inze@ albicantes, 
seen on the abdomen after pregnancy and tumors, 
also on the breasts, and on anasarcous legs. It also 
occurs as an zdiopathic condition without known 
cause, constituting the stvz@ atrophice, and macule 
atrophice ; these appear as separate, white, slightly 
depressed spots, long or rounded, exhibiting evident 
atrophy of the deeper structures, and may be found 
in any situation. 


2. Atrophia senilis. Senile atrophy of the skin 
is mainly important as being a factor in the causa- 
tion of the pruritus which is common in old age. 
The senile alterations which take place in the integ- 
ument are characterized by thinning of the whole 
skin and atrophy of the papillary layer, alteration in 
the sebaceous glands, and a diminution in the elas- 
ticity and extensibility of the skin. 


C. ATROPHIES OF HAIR. 
Four states are located in this group, ordinary 


ATROPHIC AFFECTIONS. 239 


alopecia, alopecia areata, the curious alteration known 
as trichorexis nodosa, and fragilitas crinitum, 


1. Alopecia. Synonyms: Alopecia vulgaris ; Tri- 
chorrhea, Defluvium capillorum. Baldness may re- 
sult from many different causes, and exhibits differ- 
ent characteristics accordingly; it may be spoken 
of as symptomatic and idiopathic. 

SYMPTOMATIC BALDNESS.—The hair may fall asa 
result of severe sickness, and also after pregnancy, 
and as a consequence of a number of diseases which 
affect the scalp ; these are syphilis, erysipelas, eczema, 
psoriasis, seborrhea, favus,and ringworm, also any 
ulcerating disease, as /upus. In addition to the loss 
of hair caused by ulcerating lesions, there are two 
periods at which ‘syphilitic alopecia is met with ; 
first, during the earlier stages, in conjunction with 
general eruptions, iritis, etc., and second, during a 
later period, from the cachexia sometimes observed, 
accompanied with seborrhoea. The hair lost early in 
syphilis, and in consequence of erysipelas and acute 
eczema of the scalp, also from psoriasis, tends to re- 
turn as these are removed. ‘The most fertile cause 
of baldness is seborrhcea, and also a low grade of 
chronic eczema; both manifest abundant scales or 
dandruff, those of seborrhcea are more greasy, while 
in eczema there is commonly considerable itching. 
Long continued favus is very prone to leave per- 
manent baldness by destroying the follicles, causing 


240 MANUAL OF DISEASES OF THE. SKIN. 


scarring ; ringworm seldom does more than to tem- 
porarily destroy the hair. 

IDIOPATHIC BALDNESS.—This results from failure 
in the hair producing powers of the follicles, and 
that which is a natural event in advancing age, may 
occur as disease during early years. Premature loss 
of hair is common in some families, as also early 
turning gray, and where this strong hereditary tend- 
ency exists it is very difficult to arrest the falling or 
to restore that which is lost. The history in the 
family of early falling of the hair, however, need not 
always indicate an unfavorable prognosis, because 
each case may have been due to causes which were 
remediable.. 

Etiology.—Debility and dyspepsia, either directly 
or through the agency of squamous eczema or 
seborrhcea, are the most frequent causes of early 
loss of hair, together with the absence in the food of 
the phosphates found in whole wheat. Continuous 
and severe mental application, likewise severe nerv- 
ous strain can also cause the hair to fall. 

Treatment.—Symptomatic baldness is treated by 
measures suited to the condition present, and by 
the subsequent use of stimulating hair lotions (For- 
mulz 49, 50, 51). Where cicatricial tissue has 
formed, all efforts are of course useless. It is very 
important to determine whether slight, chronic ec- 
zema is present, or seborrhoea, for unless these con- 
ditions are recognized and treated properly but little 
permanent gain will result. 


ATKOPHIC AFFECTIONS. 241 


2. Alopecia areata. Synonyms: Avea Celsz , Por- 
rigo decalvans ; Tinea decalvans,; Pelade. ‘This is 
characterized by the appearance upon an otherwise 
apparently healthy scalp of one or more sharply de- 
fined, perfectly bald, smooth, white, and shiny spots, 
which may remain and increase in size, or slowly re- 
gain their. normal condition by a growth of fine 
downy hair. The disease usually appears very sud- 
denly, and often on awaking in the morning the 
patient or friends will discover a spot, generally 
roundish, completely devoid of hair, of a size vary- 
ing from half an inch upward in diameter. The 
most common seat for the first appearance of the 
disease is either parietal region, or the top of the 
head. The beard may also be affected either pri- 
marily or later in the disease. The condition may re- 
main stationary for a considerable period, or may 
advance rapidly or slowly, even until every hair is 
removed from the entire body. In certain rare cases 
all the hair of the scalp will be loosened at once and 
come out with the slightest touch at any point. 

Etiology—The cause of the falling of the hair 
must be looked upon as neurotic, although opinion 
is still divided as to its true nature. Many have con- 
sidered it to be caused by a vegetable parasite, to 
which the name mzcrosporon Audouint has been 
given; repeated and careful studies by competent 
observers have failed to find the fungus, and the 
parasitic theory is abandoned by most recent writers. 

II 


242 MANUAL OF DISEASES OF THE SKIN. 


After repeated and thorough search I have never 
been able to find the parasite; the youngest patient 
I have seen affected is a girl of six, the oldest a man 
of fifty-four. 

Diagnosis—The only eruption liable to be mis- 
taken for alopecia areata is ¢7ea tousurans: as a 
rule this presents the symptoms described, but oc- 
casionally will exhibit quite bald and “smooth 
patches, much resembling the disease under consid- 
eration, and the question arises whether the tricho- 
phytic disease may not by nerve irritation induce 
true alopecia areata. 

Treatment.—Internal treatment has very little 
immediate effect, but should never be neglected ; 
it should always be tonic, with especial reference to 
the nérvous system (Formule 55, 60, 64). Phos- 
phates should be supplied in the diet, as in bread 
from the whole wheat; also fats. The local treat- 
ment is embraced in the single word stimulation: 
small patches may be blistered with advantage; 
where a large surface is involved stimulating 
lotions (Formule 49, 50, 51), are applicable, in- 
creased in strength, with acetum cantharidis until 
their action is severe. Sulphur ointment, well rub- 
bed in, is also a good application. Injections 
under the skin of the nitrate of pilocarpin, one- 
tenth grain every few days, will sometimes act won- 
derfully well. 

Prognosis.—This should always be guarded, as 


ATROPHIC AFFECTIONS, 243 


occasionally the disease will prove most rebellious 
even for years. 


3. Trichorexis nodosa. This consists of a pe- 
culiar alteration in the shaft of the hairs, whereby 
nodosities, of a whitish appearance, occur singly or 
‘at intervals along the hair; the hair is liable to 
break at these swellings, and the ends have a brush- 
like appearance. It is most common on the mous- 
tache, and beard, but has also been observed on the 
scalp. It is not parasitic. 

LTreatment.— Repeated shaving and inunction with 
the oleate of mercury, five per cent. solution, affords 
the best prospects, but often the disease proves 
very rebellious, the nodules reappearing as soon as 
the hairs attain sufficient length. Constitutional 
treatment has little if any effect. 


4. Fragilitas crinium. Synonym: Afrophia pr- 
lorum propria. In this the hairs fracture easily, gen- 
erally breaking only in part, then stripping down 
the shaft. In other instances they break at their 
exit from the skin, and the illy-growing hair irritates 
the follicle. 

A number of other curious mis-growths of the hair 
have been reported, which cannot be noticed here: 
not very infrequently it will be seen to curl itself up 
just beneath the epidermis, and sometimes cause 
considerable irritation. 


244 MANUAL OF DISEASES-OF THE SKIN, 
D. ATROPHY OF - THE’ NAIL. 


Atrophy of the nail is generally due to diseases 
affecting the skin extensively, or the region of the 
nails alone; it may also appear independently of 
other disorder than an imperfect formation of nail 
substance. 


Onychatrophia. Synonyms: WDegeneratio un- 
guium , Mollitres unguium. In psoriasis the nails are 
apt to be covered with little pits or apparent 
erosions; in eczema they may be mal-formed, and 
either thin or thickened. In phthisis the nails are 
thin and apt to be curved. As an idiopathic con- 
dition we occasionally find the nails thin, fragile, 
and easily split when buttoning the clothes; in 
other cases the nail is furrowed lengthwise. After 
severe sickness an atrophic furrow appears as the 
nail is growing out, corresponding to dhs date and 
duration of the illness. 


OTE Rae Dee 


CLASS VIII. NEOPLASMATA.—NEW FORMATIONS. 


Two subdivisions occur in this class, relating to, 
I. Benign new formations, and, IJ. Malignant new 
formations; these differ more in their clinical fea- 
tures and tendencies than in any pathological char- 
acters. They are all characterized by a deposit of 
elements which may correspond with the normal 
tissues of the skin, as connective tissue, blood vessels, 
lymphatic tissue, etc., or of cellular elements which 
destroy the life of the part and produce scars. 


wh Benign New Formations. 


THE diseases in this division give trouble by 
their presence and unsightly character rather than 
by any tendency to cause great pain or to destroy 
life; eleven diseases are thus classed in six sub- 
groups: New formations, A, of connective tissue; 
B, of fatty tissue; C, of granulation tissue; D, of 
blood vessels; E, of lymphatics; F, of nerves, 


A. NEW FORMATIONS OF CONNECTIVE TISSUE. 


Three-diseases are grouped here, kelord, fibroma, 
and xanthoma. 
245 


246 MANUAL OF DISEASES OF THE SKIN 


I. Keloid. Synonyms: Kelis; Cheloid,; Chelo- 
zdea. This is a flat or rounded new growth of 
connective tissue, smooth and firm, generally of a 
reddish color, and of various shapes, usually pre- 
senting claw-like projections, and bearing much re- 
semblance to the cicatrix from a burn. Writers 
have often spoken of a spontaneous or true, and of a 
cicatrical or false keloid; it is questionable if in- 
every instance the disease does not arise from trau- 
matism, although individuals vary greatly in. their 
tendency to the production of this new growth. It 
is observed to follow all sorts of injuries, also se- 
verely ulcerative affections, syphilitic and other, 
although generally the traumatic cause is unrecog- 
_ nized; the front of the chest is a favorite location. 
It is more common, and apt to be larger in negroes 
than in the white races. The cause is unknown. 

Diagnosis.—This is usually simple, owing to the 
peculiar features belonging to the disease; it is dis- 
tinguished from ordinary scars by its tendency to 
spread slowly, and by pricking pains which generally 
occur. 

Treatment.—No treatment is of much, if any, avail ; 
destruction or removal in any way is generally fol- 
lowed by reproduction of the disease. 


2. Fibroma. Synonyms: Molluscum fibrosum ; 
Molluscum simplex ; Molluscum pendulum. Yhis con- 
sists of soft, roundish tumors, of various sizes, either 


NEW FORMATIONS. 247 


pedunculated or imbedded in the skin, and of the 
color of the normal integument, unless when irritated 
or inflamed. There may bea single one, or multi- 
tudes; over three thousand have been observed on a 
single person. In some instances they have long 
pedicles and occasionally may attain great size; they 
consist of connective tissue with more or less serous 
and mucoid elements. 

Diagnosis —The tumors differ from acne mollus- 
cum in being solid, and having no central opening; 
fatty tumors or /zfomata are apt to be lobulated and 
more flat; sarcomata are more round and solid. 

Treatment.—Removal by excision or ligature. 


3. Xanthoma. Synonyms: Xanthelasma: Viteli- 
goidea: fibroma lipomatodes. This is characterised 
by the presence of one or several spots or patches of 
yellow or buff-colored tissue, either on a level with 
the skin or slightly raised, smooth and velvety on 
the surface. It is most commonly seen upon the 
eyelids, in patches of varying size and shape, but 
may also affect many portions of the body; it is 
much more frequent in females than males, and is 
rare in children. 

Two forms of the eruption are spoken of, xan- 
thoma planum, and xanthoma tuberosum , in the for- 
mer, the new deposit is evenly disposed, and in the 
latter, gathered more into small nodules or points ; 
in a very striking case still under my care the 


248 MANUAL OF DISEASES OF THE SKIN. 


nodules exist in considerable numbers on the el- 
bows, and moderately below one knee, while on all 
the lines of flexure of the hands the yellowish de- 
posit is in streaks quite on a level with the skin. 

Etiology. —Liver disorder is thought to be a cause, 
as jaundice has been observed to precede the erup- 
tion in a certain number of cases; the connection 
and true causation is still doubtful. 

Diagnosis —The lesion can hardly be mistaken, 
there is no other which resembles it. 

Treatment.—Excision, .where practicable, offers 
about the only means of cure; where the disease is 
recent and progressing with evident liver disorder, 
as in the case of xanthoma multiplex, the latter should 
receive careful and thorough attention. 


B. NEW FORMATION OF FATTY TISSUE. 


Lipoma.—Fatty tumors belong rather to the sub- 
cutaneous tissue than to the skin proper, but they 
are introduced here because of their frequent im- 
portance diagnostically. They are characterized by 
their indefinite outlines, their soft and flabby feel, 
and their mobility with the skin, which is normal 
over them ; they may be of any size, and are seldom 
abruptly elevated. 

Diagnosis —Lipomata may be mistaken for car- 
cinoma, lymphangioma, sarcoma, and a_ syphilitic 
gumma, 


a 


NEW FORMATIONS. 249 


C. NEW FORMATIONS OF GRANULATION TISSUE. 


This group embraces three diseases, lupus, scrofu- 
loderma, and rhinoscleroma ; these approach closely 
to the second division, namely, malignant new for- 
mations, in their pathological features, as well as in 
their occasional destructive tendency. 


1. Lupus. The two conditions, lupus erythema- 
tosus and lupus vulgaris, which are classed under this 
name, differ from each other in so many respects 
that it is desirable to treat of them quite separately. 

LUPUS ERYTHEMATOSUS.—Synonyms: Lupus ery- 
thematodes ; Lupus sebaceus; Seborrhea congestiva ; 
Scrofulide erythemateuse. This is characterized by 
the presence upon the skin of one or more patches 
of infiltrated tissue, presenting’ congestive redness, 
and of a smoked-ham color, tending to become cov- 
ered with grayish brown, adherent scales; upon the 
forcible removal of the scales from patches occur- 
ring upon the face, they are found to have prolonga- 
tions from their under surfaces, which extend into 
the ducts of the sebaceous glands, which are thus 
left gaping, giving much the appearance as though 
a needle had been thrust into reddened wax. 

The beginning of the disease is often so slight 
that a correct diagnosis cannot be made; there is 
only a rather dusky, generally circular, erythema- 


tous point or patch, which persists in spite of medi- 
1B to 


250 MANUAL OF DISEASES OF THE SKIN. 


cation, gradually thickens, and becomes scaly, ac- 
companied with occasional pricking sensations; it 
is always dry from beginning to end. The most © 
common location is the face, and especially the nose 
and cheeks, although the disease may attack any 
portion of the body; the eruption may involve a 
considerable region by extension, or by the appear- 
ance of new spots; in ‘certain rare cases the 
disease may develop rapidly over a considerable 
extent, and even be accompanied with constitu- 
tional and febrile conditions. 

Fathology.—While in the fully developed disease 
there is found cell infiltration which leads to destruc- 
tion of tissue and scarring, the earliest phases ex- 
hibit mainly the phenomena of inflammation; it was 
once thought that the disease originated in the se- 
baceous glands, hence the name first proposed by 
Hebra, seborrhea congestiva, but recent investiga- 
tions have shown that it may begin in other struc- 
tures as well. 

Diagnosis.—The eruption is liable at times to be 
mistaken for /upus vulgarts, seborrhea, chronic eczema, 
psoriasis, erpthema multiforme (circinatum), ringworm, 
syphilis, and non-eroding epzthelioma. In rare cases 
erythematous lupus develops into lupus vulgaris, but 
commonly is distinguished from it by the absence 
of the pulpy tubercles belonging to the latter. 

Treatment.—Lupus erythematosus is always a re- 
bellious disease, and is very little affected by inter- 


NEW FORMATIONS. 251 


nal medication; phosphorus will sometimes act very 
favorably, iodide of starch (Formula 75) has also’ 
been recommended. Local treatment is of most 
service, but also often proves insufficient to remove 
the disease, and cannot prevent the development of 
new patches. The treatment is stimulating, sooth- 
ing measures having but little effect. Soapy solu- 
tions or those of caustic potash (Formule 16, 38, 39) 
well rubbed in are most highly recommended; they 
often cause considerable inflammation, but are fol- 
lowed by absorption. The emplastrum mercuriale 
(Formule 18, 19) is also of value. Erasion, or 
scraping with the sharp spoon, is an effective plan 
of treatment, as also multiple scarification, repeat- 
edly employed; the actual cautery produced by 
Paquelin’s apparatus, or by galvanic action, is also 
of service. | | 

LUPUS VULGARIS.—Synonyms: Lupus exedens ; 
Lupus tuberculosus, Lupus hypertrophicus, Noli me 
tangere,; Scrofulide tuberculeuse. True lupus is rare in 
this country, but twenty-five cases occurring in the 
8,000 analysed, or about three per thousand ; tubercu- 
lar syphilis which may simulate lupus, and to which 
the term syphilitic lupus is sometimes given, is ex- 
cluded; true lupus has no connection with syphilis. 

Lupus vulgaris consists of a new deposit of cellu- 
lar elements, forming reddish or brownish masses, 
which are soft and pulpy, more or less translucent, 
and are followed by cicatrices. The cellular deposit 


252 MANUAL OF DISEASES OF THE. SKIN. 


may be in distinct papules or tubercles, or, as is fre- 
quently the case, may infiltrate larger portions; in 
older cases an evenly affected surface is often seen, 
interspersed with cicatricial bands, and covered with 
epidermal scales of some size, firmly attached on 
one edge, or more rarely with crusts over some por- 
tions. Many of the cases presenting great ulcera- 
tion and destruction of tissue, formerly called lupus 
exedens, and nolz me tangere, touch me not, are now 
recognized to be epithelioma or rodent ulcer, and 
syphilis. True lupus is very rebellious and may 
cause disfigurement and distress, but very rarely 
makes the inroads described in older books as be- 
longing to the disease, whence the Latin name lupus, 
a wolf, was derived. It is most commonly seen upon 
the face and extremities; it generally commences 
in young life, before twenty, and rarely, if ever, be- 
gins after fifty years of age. 

Diagnosts—Lupus vulgaris is most frequently con- 
founded with tubercular and gummy syfhilis, also 
with lupus erythematosus and epithelioma , it should 
never be mistaken forother eruptions. The history 
and the rapid development of the lesions of syph- 
ilis, together with their characteristic grouping, their 
tendency to heal and reappear, and the crusts gen- 
erally seen, should suffice to distinguish the syphi- 
litic eruption. 

Treatment.—This is frequently very unsatisfac- 
tory; internal measures have comparatively little 


NEW FORMATIONS. 253 


effect, but every element should be attended to look- 
ing toward improved health and nutrition. Cod- 
liver oil is often of some service, also phosphorus 
and iodide of potassium. Local measures, to be 
effectual, must be energetic; the disease itself pro- 
duces scarring, and the object of treatment is to de- 
stroy diseased tissue and to substitute healthy inflam- 
matory action for disease. Nitrate of silver in stick, 
thoroughly bored into the nodules until healthy tissue ° 
is reached, is one of the best measures; the surface 
is to be covered with picked lint, which dries into a 
crust and falls off in some days; any remaining disease 
should be immediately attacked anew. Caustics in 
paste or ointment, as arsenic and red iodide of mer- 
cury (Formule 12, 15) answer if efficiently applied, 
but are slow and painful; also acetate of zinc in 
crystal, and chloride of zinc. The actual cautery, 
erasion with the sharp spoon or curette, and mul- 
tiple scarification are also of great service in the 
treatment of lupus. 

3. Scrofuloderma. While lupus is often seen in 
strumous patients, and by many is regarded as a 
scrofulous affection, this is not always the case; 
the present term is employed to represent other 
changes in the skin and subcutaneous tissues than 
lupus, which are observed in those exhibiting more 
clearly the marks belonging to that illy defined but 
still practically acknowledged condition or state 
called scrofula or struma. 


234 MANUAL OF DISEASES OF THE SKIN. 


The most common form of disease is that ob- 
served to take its origin from lymphatic glands, as 
when they become enlarged and suppurate beneath 
the jaw, or in the region of the clavicle; here the 
resulting cutaneous ulceration -is of a purplish red 
color, with undermined edges and indolent, granu- 
lating base, bleeding easily, with a sero-purulent dis- 
charge, often coming from’a sinus communicating 
with the ulcer. A rare form of scrofulous disease is 
seen in the form of rather hard, dark red elevations, 
sometimes verrucousin character, tending to ulcerate 
and to become covered with crusts; at times they 
are fungoid and give exit to sero-purulent discharge. 

Diagnosis.—-The exact conditions of disease of 
the skin which are to be grouped under the name 
scrofuloderma are by no means well defined as yet, 
and differentiation is to be made rather by exclusion 
than by peculiar features which are entirely charac- 
teristic. These lesions mostly resemble syphzlzs, 
lupus, and epithelioma. 

Treatment.—The most careful and complete treat- 
ment for the scrofulosis is that most appropriate for 
the diseased skin, with such remedies as cod-liver 
oil, iron, lime, etc. Locally the preparations of 
iodine, as the compound iodine ointment, aid absorp- 
tion; mercurial ointments (Formule 92, 93, 102, 103) 
are also of service. The process tends to produce 
scarring, and if left to itself-is very tedious; the 
earlier that radical measures are undertaken the’ 


NEW FORMATIONS. 206 


better; erasion with the curette is often the best 
method of treating the strumous deposit. 


-3. Rhinoscleroma. This curious affection, which 
is almost unknown in this country, was first de- 
scribed by Hebra and Kaposi in 1870. It consists 
of a very hard, dense formation about the nose and 
its immediate neighborhood ; the surface is either of 
normal color, or of a light or dark, brownishered 
shade, and may be either flat or raised into promi- 
nences ; it has little or no tendency to ulcerate, and 
heals kindly, but is reproduced, after destruction or 
excision. The mass gives little trouble except by 
its increased growth, but is somewhat painful when 
pinched. It has no connection with syphilis, and is 
quite distinct from epzthelioma and lupus. 

Treatment.—This is extremely unsatisfactory; Ka- 
posi states that no successful method of treatment 
has been found. He had observed twenty-five 
cases. 


D. NEW FORMATIONS OF BLOOD VESSELS. 


Two diseases are placed: in this group, z@vus vas- 
culosus and telangiectasts. 


1. Nzvus vasculosus. Synonyms: MWevus san- 
guineus,; Claret stain; Port-wine mark; Mother's 
mark. Yhis consists of a new growth of blood-ves- 
sels, congenital or appearing shortly after birth, pre- 


256 MANUAL OF DISEASES OF THE SKIN. 


senting various appearances. It may be a mass of 
larger vessels, and form a tumor of a round or oval 
shape and of varying size and height; or it may be 
composed only of smaller capillaries and be level 
with the surface. The latter constitutes what is or- 
dinarily known as port-wine mark or claret stain, 
called also mother’s mark and birth mark, and may 
vary from a trifling disfigurement to a hideous de- 
formity, covering much of.the face or even of the 
body. The color varies from an arterial red to a 
bluish purple. In larger nevi pulsation is often very 
distinct. 

Treatment.—Larger cavernous nzvi requires sur- 
gical operation, or they may be treated by electroly- 
sis, with the introduction of needles connected with 
the negative pole into them, the positive pole being 
placed above. Superficial nevi may be destroyed 
with caustics or with the actual or galvanic cautery. 
Multiple scarification, electrolysis, and multiple punc- 
ture, with the introduction of carbolic or chromic 
acid, have also been used with success. 


2. Telangiectasis. In distinction from congeni- 
tal vascular new growths or nevi, this term is ap- 
plied to those which appear later, generally in early 
adult life. Various forms and degrees are observed ; 
the slightest is that appearing generally about the 
face as a minute red dot from which several small 
vascular lines radiate, the mevus araneus, or spider 


NEW FORMATIONS. 257 


nevus. After lesions which produce cicatrices there 
is frequently a telangiectasic condition of the capil- 
laries, which are tortuous and dilated. This state is 
often seen upon the nose and cheeks in connection 
with acne rosacea, and to this the term vosacea alone 
has been applied. Varicose veins also belong in 
this class. je 

Treatment.— Naevus araneus may be easily re- _ 
moved by boring into the central vascular point 
with a caustic: a convenient method is to use a 
sharpened match dipped in mono-chloro-acetic acid. 
The enlarged veins on the face may be obliterated 
by slitting them with a knife, and cauterizing their 
course with a stick of nitrate of silver; electrolysis 
is also valuable. 


E. NEW FORMATIONS OF LYMPHATICS. 


Lymphangioma. Synonym: Lymphangioma tu- 
berosum multiplex. This very rare affection consists 
of the production of many, small, rounded or oval, 
brownish-red nodules, slightly painful on pressure, 
and firmly embedded in the corium. These are 
found microscopically to present circular or oval 
spaces, identical in structure with dilated lym- 
phatics. 

The cases described by French writers as “ lym- 
phadénie cutanée”’ are now thought to be forms of 
sarcoma. 

17 


258 MANUAL OF DISEASES OF THE SKIN, 


F. NEW FORMATIONS OF NERVES. 


Neuroma cutis. This term has been applied to 
a very rare affection characterized by small, firm, 
flattened tubercles, packed together or irregularly 
disseminated, which may be of the color of the skin, 
or a little reddened, and presenting a roughened 
surface. Beginning with itching, the later develop- 
ment is attended with pain, which is paroxysmal 
and very severe, radiating from the part; movement 
or pressure, also exposure to cold air and change of 
season, excite the attacks of pain. In other in- 
stances a single “subcutaneous painful tubercle” ap- 
pears. 

Treatment.—Excision of the nerves leading to the 
part has given much relief; all other measures are 
only palliative. 


IT. Malignant New Formations. 


Four diseases are grouped here, each presenting 
several clinical phases, all marked by their malig- 
nant character, tending in the end to destroy life; 
these are, lepra, carcinoma, epithelioma, and sarcoma. 


I. Lepra. Synonyms: Leprosy; Elephanttasts 
Grecorum , Leontiasis. Leprosy is a constitutional, 
malignant disease, characterized by the occurrence 
of cellular deposits in the skin and other tissues, 
producing changes which tend to destruction and 
death. Leprosy is endemic in certain countries, 


NEW FORMATIONS. 259 


especially in Asia and the islands of the sea, also in 
some sections of Europe, as Norway, and <also in 
portions of South America; it is very rarely seen in 
this country, and generally in persons who have fre- 
quented affected countries, although well marked 
fatal cases have occurred in the United States with- 
out any connection with other regions. The disease 
is frequently known as elephantiasis Grecorum, but 
it should be clearly distinguished from the elephan- 
tiasts Arabum, previously described, with which it 
has no connection. whatever. 

Three forms or varieties of leprosy are spoken of, 
lepra maculosa, lepra tuberculosa, and lepra anesthet- 
zca, but the disease is identical in every instance, 
and all forms may appear in the same individual ; 
the tubercular form often commences with macules, 
and all cases exhibit more or less anesthesia. 

LEPRA MACULOSA makes its first appearance in 
the form of macules, or with occasional bullz; the 
macules are at first red, slightly elevated, and with 
illy-defined margins; later they become brownish- 
red, and as they enlarge tend to clear in the centre; 
still later they may present an atrophied condition, 
and the eruption then exhibits pale patches, an inch 
-or so in diameter, round or oval, with a slightly ele- 
vated, dark, brownish-red, or ham-colored margin 
of considerable breath, shading insensibly into the 
normal skin. During their entire course the ma- 
cules have an infiltrated appearance; there is apt to 


260 MANUAL OF DISEASES OF THE SKIN. 


be hyperzsthesia first, and anesthesia later; the 
first sensation may be as though a hair lay on the 
surface, tickling it. Still-later, marked anesthetic 
symptoms and tuberculous deposits appear, as next 
described. 7 

LEPRA TUBERCULOSA.—Tubercular leprosy is the 
form most commonly encountered ; here irregular 
masses form within the tissues, which may be from 
the size of a pea to that of a large nut or larger, of 
a yellow, and later of a brown color. These are apt to 
develop first in the lobes of the ear and the nose, next 
on the forehead and lips; the term J/eontzaszs has 
been applied to the appearance thus presented, from 
a supposed likeness to a lion’s face. In later stages 
the tissues of other parts become the seat of similar 
deposits, which may also affect the mucous mem- 
branes, and the eye. 

LEPRA ANAZSTHETICA.—This form is seen most 
commonly in countries where the disease is en- 
demic; the nervous tissue appears to be first af- 
fected, and tickling and burning sensations are felt, 
with pain; thickening of the nerves also occurs, 
which can be especially felt along the ulnar nerve. 
Macular patches and perhaps bulle appear, and 
shortly the tissues of the fingers and toes become 
thickened and the parts feel numb; ulceration now 
readily occurs and the phalanges separate and are 
lost one by one, without pain, the stumps healing 
perfectly (/epra mutilans). The process may go on 


NEW FORMATIONS, 261 


to the removal of all the fingers and toes, and even 
of the feet and hands; or the parts may become 
shrunken and distorted. 

Diagnosis.—Leprosy may most frequently be mis- 
taken for syphilis, also for upus ; the occasional bullz 
might suggest pemphigus, and the whitened patches 
with dark borders resemble leucoderma or morphea; 
a distorted hand might resemble scleroderma. When 
fully developed it can hardly be mistaken. 

Pathology.—The lesions consist of new deposits of 
cellular elements resembling those in lupus and 
syphilis; the nerves are found to be swollen and 
darkened, mainly by new deposit in their sheaths, the 
pressure of which accounts for the nerve symptoms. 

Prognosis.—This is always bad; treatment has ef- 
fected but little in staying the progress of the dis- 
ease, even in other lands than where it is endemic; 
it may last three, five, ten, or even more years be- 
fore the patient succumbs. While in foreign coun- 
tries it is found mainly among the lowest classes, 
the cases met with in this country are often in good 
circumstances; but the best of care accomplishes 
but little. While leprosy may not be communicated 
by ordinary contagion, the experience in other lands 
shows that it is desirable to segregate lepers ; there is 
no doubt in regard to its transmission by heredity. 
Reported cases and statistics show that the disease 
is certainly on the increase in the United States. 

Treatment.—In addition to the best dietetic and 


262: . MANUAL OF DISEASES OF THE SKIN. 


hygienic management, and the treatment of symp- 
toms as they arise, powerful tonics, especially qui- 
nine, have some control over the disease. Special 
drugs have also been found of service by different 
observers, but have as often failed; these are chaul- 
moogra oil, internally and externally, gurgun balsam, 
the oil of the cashew nut, and hoang nan. 


2. Carcinoma cutis. Cancer of the skin com- 
monly arises as a secondary deposit in connection 
with cancer of other organs, chiefly of the breast. It 
is characterized by the appearance in the skin, 
especially on the chest, of small, very hard masses, 
of a pinkish or brownish red, with some hardening 
of the tissues between; the little kernels are pain- 
ful when pressed on. _ 

Another form is presented as a diffuse induration 
of the integument, more commonly first seen on the 
chest, exhibiting when fully developed a hardened 
and somewhat contracted, and shiny skin, with or 
without separate nodules, the so-called cancer en 
cutrasse. ‘This may extend and so press upon the 
blood vessels as -to cause cedema of the arms and 
much pain. 

Carcinoma melanodes, or melanotic cancer, is a 
malignant form of disease often starting from a 
pigmentary mole, which forms fungating, bleeding 
masses; other organs, often almost the entire sys- 
tem, may be later infiltrated with the disease. 


NEW FORMATIONS. 263 


Diagnosis —The diffuse forms of cancer are liable 
to be mistaken for scleroderma. . 
Treatment.—Vhis is at the best but palliative. 


3. Epithelioma. Synonyms; Fpzthelial cancer ; 
Cancroide,; Rodent ulcer. The forms and appear- 
ances of epithelioma in different degrees and stages 
vary so greatly that those unacquainted with the 
disease may fail to appreciate the lesion ; cases also 
differ very greatly in their malignity. The begin- 
ning is always very small, and commonly its real 
nature is not recognized until it has lasted some 
time; the disease may start from a mole or wart, or 
from a hardened sebaceous concretion, or begins un- 
recognized as a scaly patch, which exhibits a raw 
and frequently slightly bleeding surface, whenever 
the crust is picked or rubbed off. Soon greater in- 
filtration is manifested and more ulceration; in the 
progress of the disease small pearly tubercles, hard 
and cartilaginous are often formed, which break 
down on their summits and form ulcers. The edge 
of an epithelioma generally becomes hard and ele- 
vated, the ulcer extends and deepens, and great de- 
struction of tissues, even of the bones may result 
(rodent ulcer). Upon the lip the disease, beginning 
in a very insignificant raw spot, may increase to such 
an extent as to present a fungous mass of granula- 
tions; in occasional instances large areas of skin 
may be occupied by the disease. 


264 MANUAL OF DISEASES OF THE SKIN. 


The face is the most common seat of epithelioma, 
but no portion of the body is exempt; the lower 
lip is most frequently attacked, also the region of 
the eyes and the nose. The male and female geni- 
tals are also common locations, and the tongue and 
mucous membrane of the mouth are not rarely af- 
fected ; the process may attack old ulcers of the 
leg. 3 

Pathology—The disease is to be looked upon as a 
perverted growth of epithelial elements of the skin; 
the “ epithelial nests” are compacted masses of cells, 
arranged like the layers of an onion. 

Diagnosts.—In its beginning, when there is only a 
slight scaly patch, with a little viscid secretion or 
slight bleeding beneath, epithelioma may be con- 
founded with eczema and horny seborrhea. Later, it 
may be mistaken for /upus, the lesions of syphzlzs, 
and venereal warts, many cases, formerly called 
lupus, under the title olz me tangere, are now recog- 
nized to be epithelioma. Upon the lip and mu- 
cous membranes the disease may resemble a chaucre, 
or a mucous patch. 

Prognosis —This must vary greatly with the case ; 
if taken early and treated radically, the disease 
may generally be cured; old, extensive, and neg- 
lected or badly treated cases are always very unfavor- 
able. In some instances it runs a rapid and very 
destructive course ; the glands are seldom affected as 
in cancer, even in severe Cases. 


NEW FORMATIONS. 265 


Treatment.—This must be as early and radical as 
possible, and consists of complete and thorough re- 
moval of the diseased tissue by surgical operation, or 
deep and perfect destruction by means of caustics; 
scraping with the curette has been advised, but often 
fails to reach deeply enough to remove all the dis- 
ease. Various caustics may be used, chloride of 
zinc, caustic potassa, or Vienna paste (Formule 13, 
14, 16), or other which destroys deeply; the one I 
prefer is the arsenical paste as used by Marsden 
(Formula to) in the London Cancer Hospital. This 
consists of equal parts of powdered -arsenious acid 
and gum acacia, which are mixed into a thick paste 
at the time of using, with a few drops of water. It 
is to be laid upon the part, freed from crusts, and al- 
lowed to dry on, covered with a little cotton batting ; 
after from six to twelve hours the part is poulticed 
with flaxseed meal, with renewals every two hours 
until the slough separates and the wound is healed, 
the bit of “cotton; saturated’ with~ the caustic, 
being left adherent as long as possible. A second 
application may be required, although seldom, 
except in large or deep seated lesions ; not more 
than one square inch of surface can be safely at- 
tacked at once with the paste. 


4. Sarcoma cutis. Sarcoma of the skin is a very 
rare affection, but three cases occurring_in the eight 
thousand analyzed, all in males. It consists of few, 


- 


266 MANUAL OF DISEASES OF THE SKIN, 


or many, well defined, elastic tubercles or tumors, 
forming deep, rounded masses, with a tendency to 
reach the surface and ulcerate. The skin over them 
is, at first, of the normal color, and somewhat mov- 
able, but as they approach the surface it becomes 
adherent and reddened; or, if the sarcoma is of a pig- 
mented variety it acquires a bluish black hue (sar- 
coma pigmentosum, or melanosis). The so-called 
lymphadenoma, “lymphadénte cutanée”’ and “ my- 
cosis fungoide”’ of the French, appears to be a 
form of sarcoma, as, also, the disease described by 
Geber and by Duhring under the name “ zxflamma- 
tory fungoid neoplasm’’; the tumors in these latter 
cases developed with great rapidity. 

Diagnosis.—Sarcomatous tumors may be con- 
founded with tubercular and gummy syphilitic de- 
posits, cancer, lupus, leprosy, and fatty tumors. 

Prognosis -——This is always most unfavorable ; 
death usually results within two or three years. 

Freatment.—Nothing can be done to check the 
development of the tumors; surgical interference 
may be of service in particular situations. 


CHAPTER XX. 


DIET AND HYGIENE OF DISEASES. OF THE SKIN. 


THE subject of the effect of diet upon the skin in 
health and disease, is one which has been greatly 
neglected in the study of Dermatology, and yet is 
one which is of the utmost practical importance, and 
which should receive the careful thought and obser- 
vation of every physician. Hygiene is also of very 
great consequence, both as regards the individual 
and others. First,-of diet. 

All are more or less familiar with the acute ery- 
thema, or urticaria, occasionally resulting from the 
ingestion of certain varieties of fish, particularly 
shell-fish, also, at times, from mushrooms, bananas, 
strawberries, raspberries, etc. ; in some the eruption 
will appear whenever these are eaten, in others, only 
when the articles are stale, or when they themselves 
are in a peculiarly susceptible condition. Gross in- 
discretions in eating, as of mince pies, fruit-cake, 
rich cheese, etc., often cause acne; and many drugs 
taken internally, such as iodine and bromine com- 
pounds, copaiba, quinine, and others, frequently 
produce cutaneous lesions. 


In like manner, chronic errors in diet can induc 
267 


268 MANUAL OF DISEASES OF THE SKIN. 


alterations in the skin nutrition, although the extent 
to which this happens, and the manner in which it 
occurs are by no means clearly defined as yet. Asa 
most striking illustration may be mentioned the ef- 
fect of adeficiency in fresh vegetables in producing 
scorbutus; alcohol and tobacco also undoubtedly 
exercise a strong influence upon the skin. 

The commonly accepted signification of dieting is 
that of a famishing process, which is to be continued 
for alonger or shorter period of time, with a view, as 
it were, of starving out a disease. In the present 
connection it has a much broader meaning, and sig- 
nifies such a regulation of the quantity and quality of 
food and drink taken, its mode of preparation and time 
and method of its consumption as shall conduce to the 
restoration and maintenance of health. Diet is un- 
doubtedly of varying importance in different affec- 
ions, and in different individuals, but to a certain 
degree it is of importance in relation to every case. 
Defective assimilation and disintegration are import- 
ant factors in disease, and these defects are to be 
remedied, not by medicine alone but by the regula- 
tion of every element entering into nutrition. 

Undoubtedly a healthy appetite and sound judeg- 
ment are good guides in the matter of diet ; but un- 
fortunately every one does not possess one or both 
of these, and the surroundings of modern society 
often act very prejudicially. Not every one dis- 
criminates between taste and appetite; the ¢as¢e is 


DIET AND HYGIENE. 269 


gratified long after the appetite is satisfied, and sweets 
and indigestible articles are often partaken of in ex- 
cess. 

Eczema has often been called the “ keystone of 
dermatology,’ and.a brief consideration of dietary 
matters as related to this disease will throw light on 
those of other inflammatory affections of the skin, as 
it will be impossible, in the present compass, to con- 
sider the diet of every disease separately; we will 
first notice errors in diet constantly observed in those 
suffering from the disease in infant life. 

In infants at the breast too frequent feeding is a 
common cause of the aggravation of eczema if not 
of its production ; the breast is given every time the 
child cries, or is restless with itching, and this ex- 
cites or aggravates the digestive disorder. The 
time of feeding should be regulated, and the breast 
not given oftener than every two hours, at the 
least. 

But, again, while the times of feeding may be cor- 
rect, the nourishment may be erroneous from the 
quality of the milk furnished, which again depends 
upon diet. Those nursing eczematous children are 
often found to be taking ale, beer, porter, wine, or 
tea freely, to increase the breast milk; these should 
be prohibited and milk or gruel substituted. 

Dyspepsia, constipation, or debility in the mother 
are elements to be considered and rectified when 
nursing children with eczema are being treated ; and 


270 MANUAL OF DISEASES OF THE SKIN. 


alkalies and tonics to the mother are often of great- 
est service to the child. 

Many infants with eczema are fed erroneously, 
either conjointly with nursing or in place of it. Milk 
is the best food, and yet the majority of infants take 
starchy and saccharine substances, often in great ex- 
cess; frequently animal matter, in the form of eggs, 
beef extract, etc., is given far too freely, while oc- 
casionally it will be found that even very young in- 
fants are fed from the table with the food of adults, 
tea, coffee, (cheese, pies;Metc.. “Space sforbidsamore 
than brief allusion to this vast and very important 
subject, but sufficient emphasis can hardly be laid 
on the advantage of attending to the matter of diet 
most stringently, as a necessary item in success- 
ful treatment. The diet must also be carefully 
watched in older children. Indeed, eczema at any 
period of life requires care in this regard. 

Eczema patients are generally found to dislike 
fatty matter, whereas its use should be encouraged, 
while other hydrocarbons, sugar and starch, are to be 
diminished in the dietary. The fatty matter taken, 
however, should not be in combination with other 
substances, as in gravies, pastry, and fried articles, 
but in the form of fat of beef and mutton, also but- 
ter, cream, and cod liver or other oils. Where the 
latter are not well tolerated by the stomach, they 
may be freely employed externally. 

In regard to the diet of adults with eczema, dur- 


DIET AND HYGIENE. 271 


ing acute attacks it should be light and unstimulat- 
ing, with but little meat; while in chronic cases it 
should be the most nutritious possible, and yet sim- 
ple, all elements calculated to produce indigestion 
or mal-assimilation being sedulously avoided. 

In regard to the many substances which may enter 
the dietary it is difficult to make exact statements ; 
the matter must be guided on general principles, 
but some of the more common articles may be com- 
mented on. 

Alcohol acts very prejudicially in very many skin 
diseases, and should, as a rule, be avoided, unless in 
the greatest moderation, and with the meals. Fer- 
mented liquors are even more injurious, and fre- 
quently it is impossible to cure the eruption while 
they are indulged in; the relative harmfulness of 
some of the more common ones is about as follows: 
ale, porter, champagne, lager beer, cider, port wine, 
madeira wine, sherry, claret, white wine. Tobacco 
is certainly hurtful in acne, and in eczema of the face 
and anus, and is probably noxious in many other 
affections. ; 

Tea and coffee are seldom injurious if taken in 
ereat moderation;-but tea is often used excessively, 
and certainly does much harm in eczema, if not in 
other eruptions. 

Milk is often taken as a beverage with meals; as 
a rule, this is not well for adults, but if taken en- 
tirely alone, and on a perfectly empty stomach, it 


272 MANUAL OF DISEASES OF THE SKIN. 


forms a most valuable means of improving nutrition, 
and rarely disagrees. The preparations of malt are 
well administered in milk. 

Water may be quite as harmful as other drinks, if 
taken in excess and too cold; many cases of acne 
are greatly aggravated by the inordinate use of iced 
water with the meals, or_at other times. Much 
benefit can constantly be had by giving a cup of hot 
water half an hour before eating; the thirst is thus 
quenched, and water with the meals can easily be 
avoided. | ) 

Soup will frequently be found to cause the face of 
acne patients to flush, and to excite heat and itch- 


ing in eczema; rich, greasy soup is more apt to have ., 


this effect, but with some patients all varieties will 
produce the same results. 

Fish is commonly supposed to be injurious and to 
be interdicted in skin affections, because urticaria is 
sometimes caused by shell-fish. On the contrary, fish 
may very often be used with advantage in place of 
meat in many skin diseases, especially those exhib- 
iting nervous phenomena. 

Salted meats and salted fish are rightly thought to 
act prejudicially in skin diseases; they should be 
avoided, as also pickles, olives, rich salads, stimulat- 
ing sauces, pepper, etc. Hot breads are also injuri- 
ous, likewise gravies, the skin and filling of poultry, 
and richly made dishes. 

Acids are generally not harmful, although when 


DIET AND HYGIENE. 273 


they come from unripe fruit they prove injurious ; 
vinegar and lemons are rather beneficial in most 
skin affections: 

The use of certain articles of food requires to be 
encouraged in certain diseases, of which mention 
has been made of fresh vegetable products in scor- 
butus, fatty matter in eczema and strumous erup- 
tions, and also the whole wheat products in many 
affections. Oatmeal, on the other hand, appears 
often to be “heating,” and patients with skin dis- 
eases often do better without it. Mention was also 
made of the avoidance of excess of sweets and 
starches in eczema; these are to be guarded against 
sedulously by acne patients, and also by all those 
exhibiting gouty tendencies. Sweet potatoes, cab- 
bage, bananas, and apples often do harm to those 
with inflammatory skin diseases. 

Space forbids the developing of other practical 
matters in reference to diet, such as the guantity, 
preparation of food, and the ¢zme and mode of con- 
sumption, but they must be looked after or errors 
will occur. Very many eat excessively, others very 
rapidly without sufficient mastication, others very 
irregularly. . 


HYGIENE. 


This relates to the individual and to others; first, 
as to personal hygiene. Exercise, rest, sleep, bath- 
ing, occupation, and recreation are all items which 


274 MANUAL OF DISEASES OF THE SKIN. 


are often of importance in dealing with obstinate 
skin affections. Sedentary habits, if not a direct 
cause of, are often an obstacle to the cure of many 
eruptions ; good brisk walking, several miles daily, 
suffices, and is within the reach of nearly every one; 
while horseback riding, rowing, boxing, and fencing, 
are all excellent adjuvants. 

Proper care of the skin is also necessary, but over- 
stimulation by the frequent use of the Turkish bath 
frequently proves harmful. Occupation may be in- 
jurious in many ways; by the sedentary habits in-. 
volved, by bad air breathed, by poisonous or irrita- 
ting agents employed, by irregular hours entailed, and 
by circulatory derangements caused, as when long 
standing produces varicose eczema, or stooping devel- 
ops anacne rosacea. All these and other elements are 
to be considered in connection with particular cases. 

In regard to hygiene as related to others, this per- 
tains to the contagious diseases. The hygiene of 
syphilis is all important; the patient should be con- 
tinually warned against the danger of communicating 
the disease to others, as in connection, and by mu- 
cous patches. Scabies, ringworm, and favus cases 
should always be guarded against transferring the | 
eruption to others; and in schools and public institu- 
tions the most stringent precautions are often neces- 
sary to check the spread of the disease. The protect- 
ive measures relating to acute infectious diseases are 
familiar to all. , 


CTIART RKat xi 
THERAPEUTICS OF. DISEASES OF THE SKIN. 


THE only basis of rational and successful thera- 
peutics is a thorough knowledge of disease and of 
the action of remedies, separate and combined, and 
accuracy of diagnosis is indispensable for the suc-- 
cessful management of skin affections. The pre- 
scriptions presented in this chapter are, therefore, 
given with a view of suggesting lines of thought in 
regard to the employment of remedies, rather than 
as fixed formule to be employed in every instance ; 
individual cases vary so greatly that no absolutely 
definite prescriptions can be given which are suited 
for all, and the combinations here recorded must be 
used with discretion and knowledge, and not simply 
because the disease for which they are recom- 
mended is present. In some instances varying 
strength is indicated: in the main they are all in- 
tended for adults. 


BALNEA. 


Baths are employed for the purpose of, 1. Allay- 
ing local irritation and inflammation; 2. Softening 
the skin and removing diseased products; 3. Stimu- 

275 


276 - MANUAL OF DISEASES OF THE SKIN. 


lating the skin and promoting absorption; 4. Asa 
means of acting on the general economy in quicken- 
ing the processes of assimilation. Vapor, Turkish, 
sulphur, and mercurial baths should not be used in 
inflammatory states; in the main more harm than 
' good is done by them; in sluggish conditions they 
may be of service in quickening the circulation. It 
is needless to say that it is useless to attempt to 
sweat out “impurities in the blood” by this means. 

Medicated liquid baths should vary in tempera- 
ture somewhat with the patient, the season, and the 
effect desired; a tepid bath ranges from 85° to 92° 
Fahr.; a warm bath, from 92° to 98° Fahr.; and a 
hot bath from 98° to 112° Fahr.; to be of much ser- 
vice the patient should remain in the water from 
fifteen to twenty-five minutes or longer, children a 
less time, hot water being added if necessary, to pre- 
vent chilling. The following formule are calculated 
for a bath of thirty gallons: 


1. Balneum potassii et sodit. 


ay PORASSIT Carhonatis sed ¥. «spd sss apiais bis oie is 124|41 
Sodit \carhomatis, 25 0}. kes cate em nieae ae eee 93/30 
Pulvenis' boracis; ‘Ziyi ke Ree see ae 62/20 


M. Use in a thirty (30) gallon bath, with half a pound of starch. Gelatin, 
one pound, may be substituted for the starch, or bran, a pound or 
two being soaked in a muslin bag. 


Use: Soothing and cleansing, in sub acute eczema, and psoriasis. 
2. Balneum potassit et glycerine. 
HR Potassii acetatis, 3 vj—Z xij.......... 186/61—373'22 
CSIYCORINOP 10 WAI} Li ekivn'e Cyn otis ons fide 3201 | 


M. Fora 30 gallon bath. 
Use: Soothing and antipruritic. 


THERAPEUTICS OF DISEASES OF THE. SKIN. 277, 


3. Balneum ammonia et glycerine. 


Tye iris. tron tee ALOIMALICL, wine sm aio olen 66 
Ry Caiitioe tan SVN ft cele tras Sait et ba co dale scereies 320 


M. For a 30 gallon bath. 
Use: Slightly stimulating and antipruritic. 


4. Balneum acidi carbolict. 





BaeAcidt carbolichs so— 2 1.7. de sae 2 + 15{ — 30 
Gelatine, IDS Ts nciow «eset 6 arte e Pore 373 
Tee aR OA VES 3 Asics sneer Care a pet Oe g6o 





M. Fora 30 gallon bath. 
Use: Stimulating and antipruritic. 


5. Balneum acidi nitrict, 


PPA CLOW TICFICR Uratise ea attr toe oie ol hee fee Pe era 
Arde THU TISIPES da Se ad odes sales wil cde one 3a 


M. Fora 30 gallon bath. 
Use: Stimulating and antipruritic. 


6. Balneum sulphuris compositum. 


= Sulphuris preeipitati, 3 14,0... Seatts Sioa alstal'e er tales 62/20 
Sodi Hyposwlpnitis, 4 pio. s Fe aa ye gels vei sla wee 31/10 
Acidisulphurici diluti, 7 ss. ...36 0. 00. Sle aE Ste 15 
OU EOC LN icpneg ARR HU E TE a et we alae) staie Pa ials . 480 


M. Fora 30 gallon bath. (London Skin Hospital) 
Use: Stimulating and anti-parasitic. 


7. Balneum mercuriale. 


R  Hydrargyri chloridi corrosivi, 3 iij......5..... 11/66 
Mods ny droch lovici Syeg 245. tae watet hess lo Ui es 3/75 
BrCl ee LICE owiehe alk e See Chick toey gy Peis 480 





M. Fora 30 gallon bath. (London Skin Hospital). 
Use: Stimulating and anti-syphilitic. 


8. Balneum todinit, 


Bie lodiniiag jae S440 0. beso Seiden de leveras< 3|88— 7/77 
Potassii iodidi, % j- 31 i PER rie OES 31/10—62|20 
MAU ote OC) Retire aicishe Silas ue isha daw. oes 08 oa 480 








M. Fora 30 gallon bath. 
Use: Stimulating and absorbent, 


278 MANUAL OF DISEASES OF THE SKIN. 


9g. Lalneum brominit. 


Ep U SeBTOM INI sed xX ys bis Mae be abies eae ee is bes I|12 
POtaSsiiMOGIGL, lj stip oan wick eto ek he RAGE cae 62/20 
cate ghee cant Ra Bears, Sas see Seis ee G creme iis > ale ale vais 480 


M. Fora 30 gallon bath. 
Use: Stimulating and absorbent. > 


CAUSTICA. 


Various caustics are of service in certain dis- 
eases of the skin, but in the main they are compara- 
tively seldom required: in employing a caustic to 
destroy a new growth, care should be taken that it 
is used sufficiently strong to accomplish the desired 
result, otherwise further development is stimulated. 
Nitrate of silver, the mineral acids, and mono-chloro- 
acetic acid are all of lighter destructive power; the 
following may destroy deeply. 


10. Causticum acidi arseniost, (Marsden’s paste. ) 


3} HuPulverisiAcidi. arseniosi, <2). 0s eases ei hee 3% es 
Pulveris:eummi Acacize a Snes. sneer as = 3188 
M. Mixa little with water at the time of using, and apply 


as a thick paste to a surface of not over one square 
inch at once. 


Use: Of especial value in epithelioma. 


11. Causticum acidi arseniosi comp. (Cosme’s paste.) 





KR sCPulveris acidi arseniosi, gr. xx.......+..+-.+-+ 1|29 
Pulveris hydrargyri sulphureti rubri, 3j....... 9/88 
Unouenti aquse rosie, 34. is0. 4.00.8 k bem = miase 31|10 


UsE: Moderately destructive in lupus. 


12. Causticum arseniosi et hydrargyrt. 





R Hydrargyri chloridi mitis, 3iv...........-.... 15155 
Hydrargyri bi-sulphureti, gr. viij.......... 51 
Acidi arséniosi, Qrixij.:.s0....se0005 1 ate ious KS 

M. 


Use: A moderate arsenical caustic of value in lupus. 


LHERAPE OLLICS OL’ DISEASES OF TALS SKIN, 279 


13. Causticum acidi nitratis hydrargyrt. 
ee RV CRAP OVING Soh re nick oe ba Seta C has ceed sass anes S11TO 
Meigs vitriet (Spr Or. Ha), s letae as dceas ows oees-30 
M. 


Use: A medium strong caustic, especially useful for syphilitic lesions. 


14. Causticum zinct et antimonit chloridi, (Canquoin’s paste). 


Teer CIDCh CULOTIC iy see hou esate. oa cacasrem es he 
Antimonime.chiortdiy adi 5 tases sae ees ose-s 3 ee 3/88 
Pulveris, ainyll, o sscy oe taste. once es Sen wrens? 5/82 
WGtee , CS semt at ts seams fae cae t oh ats 28 


M. Make into a paste at the time of using. 


Use: A deep acting caustic, for malignant growths. 


15. Causticum hydrargyrt todidi. 


He isclravoyre iodidi rubriy se. os ps hag es, ose 4 5,n5.0 
Unsuenti aqua noses, als ips Wa dp sets ae hae 7177 


M. et ft. unguent. 


Use: A superficial destructive, of value in poe: 


16. Causticum polasseé caustica, 


Tep Potasees Caitsticzy oT Vi—— Slpsts a cae 32a Te 7 
Ach finan Weenie lala «sda olen a a eMhete, 5 64 aeeaal 
M.. et ft. solutio. 


Use: Inweakest solutions a mild stimulant in acne, eczema, and psoriasis ; 


in strongest solutions, a medium caustic, in diffuse lupus. 


17. Causticum sodii ethylatis. 


Heicoam eth ylation: sss. eda oe sake aoe. we EG TaE 
AICOHOr ausolutae SV Jocans s.0 deat c ae tetas ss 23132 
M. 
Use: Superficial caustic in vascular and pigmentary nzevus. 
EMPLASTRA. 
18. Emplastrum mercuriale. 
Ee) Hydraroyri, 3... i. 1 28a n Po ricend Seen on eee 31/10 
Oleeierenintnitis @ S540 cache as ucla a iis eee ns ee L3i5O 
RmpisstrarplUnvore ct Vrat edt: et as toe airs 29> ¢ 124/41 


M. Spread on linen and apply closely to the part. 


Use : In chancre, syphilitic lesions, lupus erythematosus, and sycosis. 


280 MANUAL OF DISEASES OF THE SKIN. 


19. Emplastrum hydrargyri compositum. (Emplastrum de Vigo). 


(PER a huchejeca ys hy Si igre Oe COC og te, tasee nes Oe wee Be sis 
Olei terebinthine, Mxx......... Perse ete onthe 1/12 
Were tHavcey ot. XX fost we es 2 spine aie ee ae Meee Teo 
FROSINS? UOT; X13. a) .ue aria c mteka ne ee aa iate sialic s a 2/59 
SLY LACIS, 5 Pots sum sly tea atin Peele teeta ols (eminent ee <a SO 
Emplastri plumbi, 2 j.'s < <<\dac. v0 ees dine gale 7 Ouro 


M. Spread on linen and apply closely to the part. 
Use: In syphilitic eruptions, acne rosacea, and sycosis. 


20. Emplastrum depilatorium,. (Epilating stick). 





Bt Cefse faves, “3 inj... 2: Be Aad Ndi tn ke Arar Oe RE FS T1/66 
Laces in Mtabulise as evet.ae tine hcanea 8 t age hee - 5/55 
Picis ‘birgundicee< Fa Se es ae! Se Sse 38/87 
Gumimiidaman,=Ssstccu orem © ey ci eee 46/65 

M. Make into sticks half an inch to an inch in diameter and two inches 

in length. 


Use: Applied with heat to extract the hairs in favus; also in hirsuties and 
some cases of tinea tonsurans. 


GLYCERITA. 
21. Glyceritum pluméi, (Squire’s glycerole of subacetate of lead.) 
By Serlumbiacetatis, 26 SOxxs\. hee eens ees co's Thee 
Plum Oxtdy Ori 1Xexiven.  oate tee ois ke teases  o5 44 
GIy Semi mat 68 hs bic stoic ce ste oe hate cette ot 40| 


Digest the acetate of lead and the litharge in the glycerine (heated to 300°) in an 
oil bath, for half an hour, constantly stirring. Then filter in a chamber 
heated to 300°. 

Use: Diluted from three to seven times with water and glycerine as an as- 

_ tringent and sedative in chronic eczema. 


22. Glyceritum acidi tannict. 


Bi Acid tanniety « &-j. tory. s aes «lem amie e in ers 31/10 
Gy Cerinaa eR AY Cine) a aye we cis se ben preretee te ie 160 


M. Rub well together and heat slowly till dissolved. 


Use : Diluted with water as an astringent in seborrhcea and chronic eczema, 
also in herpes preputialis. 


23. Glyceritum picis liquide. 


Roper Licis liquideey 1} 0 < Saat oak ae cee) Soe Ae 77 7a = 
Wlaonesl CArDOnauis, StVacw cs ae ks sik sie Wo cals\ts 15/55 
SIV ECR a dake neh area e attr feo. 5k Tata bees 40 
PMCON OIE? SS ns Gata ss ewes See hs Pk sie oe 13/50 
ACIRS, SB UGS ta wets Nos eles os ead P¥R eb eT 75 


M. Apply diluted with water, if irritating. 
Use: An antipruritic in chronic eczema, and diluted in acute conditions. 


THERAPEUTICS OF DISEASES OF THE SKIN. 281 


24. Glyceritum amyl. 
Bea Bulveris amyliji3 7, 5 ed se eee eee cates hseae 31:10 
Giyicerince, 3 Vip ctejen es tiv da Aneg eee ents 8's 320 
M. Rub together till mixed, and heat slowly, with stirring. 
UsE: Emollient,.as a substitute for fatty substances in ointments. 


LOTIONES. 

In preparing lotions containing mineral ingredi- 
ents, great care should be exercised to avoid coarse 
and gritty particles, which -can readily irritate a 
delicate skin; the ingredients should be very care- 
fully pulverized and intimately mixed. When a lo- 
tion containing a powder is applied, the resulting 
deposit should form a smooth, even, non-irritating 
coating; as a rule, parts to which lotions are ap- 
plied should be kept continually moist with them, 
but not covered with oiled silk or too heavy dress- 
ing, as the application is then converted into a poul- 
tice. Glycerine is not well borne by every skin, and 
its place can be supplied by other demulcents. 

/ 


25. Lotio calamine et glycerine. 
BR Pulveris calamine preparate,3ss—3j 1/94— 3/88 


VANS Sose Ohm econ |e he a es a 3|\88— 7/77 
Gly Cerne © 5, jet ll fot. owas wet ah Nas pte i A 
Aqnze rosz,) Sivas tie see wees 120 


M. et ft. lotio. 
Use: Cooling and slightly astringent in erythematous conditions. 


26. Lotio calamine et crete (Startin). 


BR CPulveris calaminz preparate, 3j...... 3/88 
Gretsoeprepatatas, 3 jm 3. seins ae oes 3|88— 7177 
Acidi hydrocyanici diluti, 3ss........ I|go 
Ghy center Sj 3 Pues os cad oe kale « Ioj— 20 
EXQUONS Calcio mails sae sinet ooo Oe 0 s6 go 
WAGUre samintel,: Cee Viljs n+ es ot ,= = 240 


M. et ft. lotio. 
Use: Cooling and antipruritic in subacute inflammation, 


250 MANUAL OF DISEASES OF THE SKIN. 


27. Lotio bismuthi et amygdala. 








= Bismuthi ssub-nitratis,3 iss... 22: 5/83 
Acidi hydrocyanici diluti, 3ss—3j... I/90— 3/80 
Emulsionis amygdale, Ziv.......... 120 
M. et ft. lotio. 
Use: Antipruritic in eczema, withanbroken surface. 
28. Lotio zinct et plumét. 

. .Zinci oxids, § j-— oS ue bo eae eee 3\88— 7|77 
Liquoris plumbi sieaccnstic dil 3 vj. 22/50 
Glycerine, 3 jee dv oe ae eee eee Io| —20 
Intusiipicis diquide, wz 3 iv. itis. +s =. 120 

M. et ft. lotio. 

User: In erythematous conditions. 
29. Lotio boracis et camphore. 

Eh sPalvenls boraris, 35 923i sae ee ere 3/88 
Tincturze camphoree, CS peek PIE pean 3|40— 6)80 
Glycerine, 3 j— 3 llj ....... 0... sees - 5\— 15 
Aque aurantii florum, ad Ziv......... 120 


M. et ft. lotio. 
Use: Soothing and softening in chronic erythematous eczema, and pruri- 


tus. 
30. Lotio plumbi et opti. 
R  Liquoris plumbi subacetatis diluti,............ 
Dincturse Opi, qa2 42) ss 6s «aw seu ketenes 30 
Gules ad Oli oh valencia does ep alae stew Res 480 


M. et ft lotio. 
Use: Antiphlogistic in acute inflammatory conditions. 


31. Lotto plumbi glyceriti. 


BR Glyceriti plumbi subacetatis, 3 j— 3 iv. 
(Squire’s glycerole of the subacetate of 


lead, 4 Formula 21)54 sto se = om 5) — 20 
Glycerinz, 3 ij... kee Rae tiers knees te 10 
Aquez rose, ad Ziv..... pe cease e bins 120 


M. et ft lotio. 
Use: Astringent and sedative in chronic eczema. 


PHERAPEOLTICSIOR DISEASES OF THE: SKIN. 283 


32. Lotto antipruritica. 


BR Foliorum belladonne,......... CET ER Ee re 
Holiomim: hyoseyami yaa CQ iva ae oe odin oes 6 15/55 
Foliorummaconitity® 3 py. 3.516. ah neee sce siete accom F100 
PRCLOTACELIC Safar cae aid o's Sate oa Uae ook: 60 


M. Macerate well in the acid for several days. 


Use: To be diluted, a drachm or so to the ounce of water and glycerine ; 
a powerful antipruritic. 


33. Lotto alba. 


Hs) Potassit sulphureti;y.5). 3.2.0. Mapes hats ae ars 
Zinc sulphatis) airs pa accas ae. Mae des ce as ae. FiOS 
Auer Toss | Bive tL isoe ted cele < OPER yl bee ER ie 20 


M. Dissolve the potash and zinc, each in one-half the water, and mix, 
Use: As an astringent in acne; glycerine ( 3 i— 2 ij) may be added if too 





drying. 
34. Lotio sulphuris. 
i. Sulphurisprecipitati, 3ss...-.. Ei, HRGEE LODO 1|94 
Giyceriite Aaa pe tia vate ie Seals vate cad viele 20 
Aquee rose, Ziliss....... i ae eee ss Beha. tOR 


M. et ft. lotio. 
Use: Asa stimulant in acne. 


35. Lotio sulphuris camphorata. 


R Sulphuris precipitati, 3 ij— Ziv..... 7,77 — 15/55 
inetures Camiphora, 51}. ou secs 750 
Eiquoris calets io Wires. es sagen bee 120 





M. et ft lotio. 
Use: As astimulant in acne. 


36. Lotio sulphuris composita. 








BR Sulphuris precipitati, 3 ss—3j..... .-  Il9q — 3/88 
Bitheris: sulphiiricn O3.ives.% eis a eos 13/50 
Spiritus vini rectificati, 3 liiss....... 94|50 


M. et ft. lotio. 
Use: Asan astringent in acne. 


37. Lotio calcii sulphureti. (Vlemingkx’ solution). 


BR Calcis vivee,: 3-1v.. 2%... Hire y pce UNE 15/55 
BEL OUEIS SUDMMatls o S.V po. 6 fan oig!ete.greieie aon s Fay eae 
PEG thee CORSE ei HE NISS Oe ae a5 6 at oie’ seeial dere. t 195) 


M. Boil together with constant stirring until the mixture measures four 
’. fluid ounces, then filter. 


Use: A powerful stimulant in scabies, psoriasis, and acne. 


284 MANUAL OF DISEASES OF THE SKIN, 


38. Lotio saponis viridis. “(Spiritus saponis kalinus of Hebra), 
Rie oapouls Vitidis, Wo tv Aiece cael eaten ee >. r24l4t 
SpPIFItus. Vint TECHNCALL <n o1jyuiae ® Me die y ces 4g 


M. Filtra et ft. lotio. 
Use: On the scalp for a shampoo, with friction, adding a little water until 


a lather is formed. 


39. Tinctura saponis cum pice. 
(Compound tincture of green soap of Hebra). 


IB» Olei, cadini,.,.2.%. Re iad. Oe ee iia tinea eee : 
PAPOMIS VITICIS, Were ee oe pela ae ee chic Ne ouetyit rece 
Spiritus yu Tectiicatiad so J..4 «se = as ss eee 30 
M geld.) Cl HOO, nt Aen eee te ey Roa ones 
Spiritus lavandule, 3 ij..... of belo b ales octet. may GOm 
Met ftlotio @ 
Use: Asa stimulant in chronic eczema. 
40. Zinctura picis. 
Ty SPiciS NGhide ro 2 5 tls seas een. em ees cies 
(vei olei rusei, ve7 olei cadini),; ...42 2. ©. sé¥ : 
Alcohol Ba 2314. re woke oe a leres .w eectens slate 4 BUE0 


M., solve, et filtra. 
Use: A stimulant in chronic eczemaand psoriasis ; to be used with caution. 


41. Lotto olet cadini. 


Ey Olel vadinl, eo 1034s tats ee ee ore 13|50— 27 
Qletamorni 03 srs enc roaeen te tee eee os 
(vel olei-lini, vel olei amygd. express.) 
Od -% AVE caters Ay Waste ces 108 


M. et ft. lotio. 
Use: Applied freely as a lubricant and antipruritic in general chronic ec- 
Zz : 


42. Liguor picts alkalinus. 


Be Picts: liquidze, 5 ts ant. are Reon eee se sas 62/20 
“Potassve CAUSE Ose Sis seetaie bore W ae win le ones 31:10 
A iheaaa naples <n y ere cao eee Bue ea ioe 150! 


M. Dissolve the potash in the water and add slowly to the tar, in a mor- 


tar, with friction. 
Use: Antipruritic and stimulant in chronic eczema; when diluted from 
ten, to twenty times, sedative in more acute conditions. 


d 


THERAPEUTICS OF DISEASES OF THE SKIN. 285 


43. Lotio glycerine et potasse. 


iia Cal VCSEL CC INe Sk RSE ce hes Ca Neds tes tae cles aul “IE 40| 
Liquoris potasse, 3 ij..... Se see. ae ae 60, 


M. et ft. lotio. 
Use: A strong antipruritic application, to be diluted if too irritating. 


44. Lotio acidi carbolci composita, 


Ese AA CHCL, CALDOMCI du Sit paa ad Waldeck sora c tee eae s wets 7/75 
POtASS) CAUSTICIS <P oi hha chore os sraseeanctete Aen c) cto ater et Al ane 3:88 
AC] IVC sel tate tetas ae ae oper RICE EB eR 120] 


M. et ft. lotio. 

Use: Antiparasitic and antipruritic ; to be diluted if too irritating. 
45. Lotito amygdale. 

32— 1'29 

94 


KR Hydrargyri chlor. corrosivi, gr. v— xx 
Ammonii chloridi purificati, 3ss....... I 
Misture amygdale amar., Ziv...... sy Ee 


M. et ft. lotio. 
User: A stimulant and absorbent in pigmentary conditions; also a para- 
siticide in vegetable parasitic eruptions. 





46. Lotio hydrargyri composita. 


Bc Wydrargyri chloridi correstvi, gr vilj.......,; 52 
ZAGRAASG UD IVALIG, ei, SS ode ain etnies ons eeogekas oor 90 w praca ee 1|94 
Plamibi acetatisy 36S... 2... « ONE reas cae OP oe case 1/94 
GUUS EQS oo pil BV ore aes oa cena ar ayainians, tee ate ee 120 


M. et ft. lotio. 
Use: Stimulant and absorbent in pigmentary conditions. 


47. Lotio flava. 
BR Hydrargyri chloridi corrosivi, 3ss..........:. 1|94 
Ae icee calciss Oye 3:8 oi cice ce caer ois SEG CR 480 
M. et ft. lotio. 
Use: A stimulant in phagzedenic ulcers, 
48. Lotio nigra. * 
Aye veLy Cnatp prin CHIOMCL Nitism, Jere see t ate ttc a'e gs 3/88 
Tiicyrvear re Palme Oiler) hash <p et eed tee bog 9 $y 480 


M. et ft. lotio. 


Use: Astringent in acute erythematous conditions, and in syphilitic ulcera- 
tion. 


286 


M. 


MANUAL OF DISEASES OF THE SKIN, 


49. Lotio plumbi ei ricint. 


Plombi Acetaus; tor Wilpon ys te op ee ates eee eases 51 
O61 Sperganaiy 9568 ure eee be ee see eet ees 1\94 
ler syicini 1s Iv oe ve ele ek esi hE coals “15/55 
Spiritus winl wréctiicatijed Bay Gor aee nee ee 108 


et ft. lotio. 


Use: Cooling and cleansing lotion for the scalp, in erythematous eczema 


and seborrhea. 


50. Lotio guinie et zinc. 


Kh mOuiniceculphatis) j.5 seu = east terres or 1)\29 
ZiaCl Sol phaus, pork es oe Sere eee eon eer 64 
Tincturse pcantharidis M5 aijcees wes s char +. see 11/66 
AlCono!  absOlUli; sca oe ee ee eee piece eee Me 
(Slycevings | (Ad w3.4V Jas ae wlan ae betes es Sis Sine £5|55 
Spiritus myfcies ad “Zvjs. 5 2. = is Shc S ed ieee 162 

M. et ft. lotio. 


'- Use: Mildly stimulating lotion for the scalp. 


R 


M. 


51. Lotio cantharidis et capsict. 





Tincture cantharidis, 3ij—2Ziv...... 7\77— 15/55 
Tinctiree capsici, (9 ij—— 1vce. saute oe 7\77-— 1555 
‘Tinetare tniicis vornices 3 iviewc. «5s L515 | 
Olé1 Ficiniy 3 j— SAV A ee eee 7\77— 1555 
PATILMs Vint YeCtCALLy Ate els Biake eke 





(vel aque cologniensis,) ad %iv....... 124/41 
et ft. lotio. 


- Use: Stimulating lotion for the scalp in alopecia. 


The following formule for mixtures represent 
Occasionally the efficient 
dose is even larger than here given: some of the 
prescriptions are quite inapplicable for children, and 


average doses for adults. 


MISTURA., 


their dosage must be governed by general rules, 


THERAPEUTICS OF DISEASES OF THE SKIN. 287 


52. Mistura ferri et magnesit. 


RS Magnesii sulphatis, 3 vj— 3 jss......... 23'32—46 65 
FP errirsalphatigg se Wire. Pes aslo yin s'e oie eae « 3/88 
Acidisulphurier-diluti; 3 te. . iha.t ee as IO 
Syrupi pruni virginiane, %j......... edo 
CUE CST Ea ee rien oe re ine OR ccpeme rt 120 


M.S. Teaspoonful in water, through a tube, after meals. 


Use: An aperient and cooling tonic in acute erythematous conditions; 
quinine and strychnine may often be added to this with advantage. 


53. Mistura potassti acetatis. 


BR - Potassii acetatis, 3 iv— % jss........... 15|55—46|65 
‘Tincture -nucissyomice, 3 ipo...) &<.4 ease Tey: 
PMEasty GUaSshes Ciel ars (stein cleo ws Si 


(ve/ tincturee cinchonz comp.), ad z iv T¥a 220 


M.S. Teaspoonful in water, after meals. 


UsE: An antacid tonic in acute erythematous affections, and in chronic 
eczema in gouty subjects. 


54. Mistura ammonii acetates, 


Hy. Potassit acctatis, 3 f= ij... oa «e008 os 3/88 —11|66 
Spiritus etheris nitrosi, 3 i1j— 3 iv....... 6|75—13]/50 
Tincture aconiti radicis, Mlxv— 3 ss.... 80— 1|70 
Liquoris ammonii acetatis, a7@Ziv...... 120 


M.S. Teaspoonful in water, on an empty stomach. 
Use: In febrile conditions in children, in eczema and other disorders. 


55. Mistura rhet et sodit. 


BR Pulveris rhei, 3 j—3ij..--..-..2-- .eee 3/88 — 7/77 
Sod) bi-earbotatis...2 56 cass oa. syeres © ee 
(vel magnesie), 3 j— 3 iij......--+----- 3|\88—11/66 
Aquze menthe piperite, Ziv.........-- 120 


M.S. Teaspoonful in water, after meals. 
Use: Antacid and corrective in eczema, and inflammatory affections. 


56, Mistura rumicts composita. 


KR Potassii acetatis, 3 ss—3j.---++++-e eee 15/55—31|10 
Tincture nucis vomice, 31j..-.+++-+-: 7/50 
Extracti rumicis radicis fluidi, 3 iv...... 120 








M.S. Teaspoonful half an hour before meals, largely diluted. 
Use: In indurated and rosaceous acne. 


288 MANUAL OF DISEASES OF THE SKIN, 


57. Mistura taraxict composita, 


By Potassit acetatis,” 25.401.) nenee aero ee wee sigh ee SaEeE TLE 
Splits eefheris HitrOsi, Z.JSSape” by <sieieni-s see 40/50 
PA Cidiaeeticn dint, Seg. ta crusten 5 it catete tate Spee e375 
Fxtractitaraxici, fuidi, 4 ajcccue ss9e sete ele . 60 


M. S. Teaspoonful on an empty stomach, well diluted. 
Use: In indurated and rosaceous acne. 


58. Mistura ferri et cinchone. 


Ferri et amm onti ‘citratis.. 392% oo cae es 3/88 
Potassiil citratis; BO 1ji.0 4 = fom ss oes oleae Fig 7 
Liquoris potassii arsenitis,3j—3ij.... 3/75— 7|50 
Tinctires.nuciS;yomicis; 54) etic. a5 0K 7\50 


Tincturze cinchonze composite, adZiv.. 120 


M. S. Teaspoonful in water, after meals. 
UseE: Tonic and alterative in eczema and chronic affections. 


59. Mistura ferro-arsenicals. 


Ferri €t ammonii citratis, 3 j2..-. 2... 3/88 
Liquoris potassii Meo icee 3 ss—3ij.... 1|g0— 7150 
Liquoris potassee, 3 CW re CS he BRS geese yee 3\75— 7/50 
Syrupi pruni virginiane, & j.. Sie Sea 
Vini ferri dulcis (Malaga), ad ‘Ziv. seine 120 


M. is. Teaspoonful after méals. 
Use: Especially valuable for children, as a tonic and alterative. 


60. Wistura arsenict chloridt. 


Rs Liquoris arsenici chloridi, 3 j—Ziv..  3/75— 15 


Acidi muriatici diluti, Siv.of 4.5% 15 
Tincture ferri chloridi, 3 ij—3 iv. 7150— I5 
Agua, wd Savi te aesare ene ieee ee 120 


M. S. Teaspoonful in water, through a tube, during or after meals. 
Use : Powerful tonic in chronic inflammatory affections. 


61. Mistura hydrargyri et potassit todidt. 


KR = Hydrargyri chlor. corros., gr.j—gr. ij, 06 12 
Potassii iodidi, 3 ij— 3 iv.... ....... 7175—. 23/32 
Ferri et ammonii citratis, 3j....... 3|88 
Lineture DUucis vomice,'34j.....c+.. 7/50 


Tincture cinchone composite, ad % iv 120 


M.S. Teaspoonful, in water, after meals. 
Use: In syphilitic eruptions, and as an alterative. 


THERAPEUTICS OF DISEASES OF THE, SKIN, 289 


BR 


M. 


62. Mistura hydrareyri et ferri. 


Hydrargyri chlor. corros, gr. j—gr. 1j, 06 13 
Potassii iodidi, 3 iij—3iv.......... I1j}66— 23/32 
Ferri et ammonili citratis, 3j.....: 3/88 


Vinii ferri dulcis (Malaga), % iv...... 120 
S. Teaspoonful after meals. 


Use: In syphilitic eruptions, and as an alterative. 


R 


M. 


63. Mistura acidi nitrict. 


Acidi nitrici fortioris, 3 ss—3j...... 2|50— 5 
SVIUPl. ZINZIDETIS, | 4 SStueue foe w see - ae 20 
Tincture gentianz composite, 3 j.... 30 
ACE, Ata 2Aly ved ates iste % = eae eae 120 


S. Teaspoonful in water, through a tube, after meals. 


Use: A bitter tonic, in cases exhibiting oxaluria and liver derangement. 


BR 


M. 


64. Mistura ferri et phosphor. 





Pinicturee fern elloridtvet.  . atte ss coe oaths ; 
Acidi phosphorici diluti, 44.3 ]......... she BO 
SVIN DE MMOBIS Si ietae cdes e's te weet die wats 80 


S. One half to one teaspoonful in water, through a tube, after meals. 


Use: An iron tonic in nervous cases. 


R 


PILULA. 
65. Pilule hydrargyrt, colocynthidts, et ipecac. 
Pilgless hy drareyrivae. ccc. doraec crise aa sts 3.8 oie 
Extracti colocynthidis comp. 44 gr. x......... : 64 
Pulveris ipecacuanhe, gr. ij....... ester taest he 13 





M. et divide in pilulas No. iv. 
S. Take two at night and two on the second night after; to be followed 


each morning by a Seidlitz powder or Kissingen water. 


Use: A moderate cathartic in cases exhibiting liver derangement. 


R 


66. Pilule ferri et aloes. 


Herr sulphatis: Cxstccatly 5: $50 vase cn es whe abies ¢ 1|94 
Pulveris aloes purificate, Dj.... ..+-sseeee eee 1|29 
Orel ge OVOMIAN CED Aific wv usnenionGtad ects coe se « 3/88 
Comte CHOMIGar sare Djs asce sta wets also e aisautt - 1|29 


M. et divide in pilulas No. xl. 
S. Take one or more after each meal, and diminish the dose and its fre- 


quency as rapidly as possible. 


Use: A tonic laxative in habitual constipation. 


290 MANUAL OF DISEASES OF THE SKIN, 


67. Lilule rhei, sodit, et ipecac. 








RRP Ovens WNC cham ee as ames ae 
Sodii bicarbonatis, 443 ss—3j...... - Ti9g— 3/88 
- Pulveris ipecacuanhe, gr. x........ 64 
M. et divide in pilulas No. xxx. S. Take one after meals. 


Use: A mild laxative and corrective in digestive derangement. 


68. Pilule ferri et arsenict. 
K Liquoris potassii arsenitis, 3j— 3ij.  3/75— 7/50 


Hern:sulphatis exsiecat,. 34. ase. wen 3/88 
Sodii bicarbonatis, 3 j—3ij......... 3\88— _ 7/77 
Extracti gentianz, 3 ss—3j......... T\94— 3/88 


M. Evaporate and divide into 30 pills. S. Take one after meals. 
Use: Alterative and tonic. 


69. Pilule hydrargyri proto-iodidi. 
hh. Dydargyri dodidi’ viridis ay iocircibs -' » sees 1|29 
Kxtracti cons alcoholici, Diljmeees pet sees eee 2/59 
M. et divide inpilulas No. xl. S. Take one after meals. 
Use: In syphilitic eruptions. 


70. Pilule ferri et potassit. 

R. Ferri sulphatis exsiccati,...... Seale leterasota iter erePeNe 
Potassii scarbonatisss nue ee oes ete ee eet eee 
Potassil tartratis, Aa! G Soins ow se sie che vs a en ate PL OSS 

M. et divide in pilulas No.xcvi. — 


S. Take, at first, one after meals and increase up to three or more after 
each meal, 


User: Power fully tonic in chlorotic cases. 


71. Pilule zinct phosphidi. 
Be Zanclsphpsphidi, otis -ccweies Soke een as Sante” 
Hxtpacti nucis VOmiCe#, aa, OTK .magieis es eur ee 64 
M. et divide in pilulas No. xxx. S. Take one every 2 to 4 hours. 
Use: Nerve tonic, in zoster, leucoderma, etc. ; 


PULVERES. 
92. Pulvis hydrargyri chloridi. 
R. Hydrargyri chloridi mitis, gr. v—gr xv.. 32— |97 
Sodii bicarbonatis, gr. x—gr. Xxx...... : 64— 1/94 








M. et divide in pulveres No. vi. 
S. Take one every other morning; for children. 
Use: Laxative and alterative in infantile eczema... 


THERAPEUTICS OF DISEASES OF THE SKIN. 291 


73. Puluis bismuthi el sodit. 


R. Bismuthi subnitratis, 3% j—4ij........ 3:88— 7|77 
Hodiebitarbonatis, 3 1pis sedesicas ts 3 T77 
Pulveéris zinziberis, O17. 2.0... 5 Retin 2/59 








M. et divide in pulveres No. xii. $%. Take one after meals. 
Use: Corrective in dyspepsia, in acne and eczema. 
74. Pulvis manganesit et pepsint. 
ye Manoaniesit OXIA MiGTige wer a\s\vcsiota' aici yietdek crore 
Pepsind porcl aca juce eee ye ate « Sostueney oles 3 
M. et divide in pulveres No. xii. S. Take one or more after meals, 
UsE: Digestive and tonic in dyspepsia ; in acne and eczema, 





75. Pulvis amyl todidt. 


Add tincture of iodine to boiled starch until it ceases to give a 
blue color and all is black. Evaporate to dryness and powder. 
Each 20 grains represents one grain of iodine, or about 15 
minims of the tincture of iodine U. S. P. 


Use: A safe method of administering iodine in late syphilis and lupus 
erythematous. 


In preparing dusting powders for external use the 
greatest caution must be exercised that they are in 
the finest possible state, and entirely free from 
gritty particles: those which contain mineral sub- 
stances should be shaken or stirred before being 
applied, as otherwise, a separation of the ingredients 
may interfere with their beneficial action. Care 
must be taken that powders be not allowed to cake 
upon the skin or to become worked into a paste, as 
in the flexures of the joints and elsewhere. 


76. Pulvis antipyreticus. 


BR Buckwheat flour— 


Use: This forms a most agreeable and cooling application if kept contin- 
ually applied in acute erythematous conditions. 


292 MANUAL OF DISEASES OF THE SKIN. 


77. Pulvis calamine compositus. 
E. oPulveris calaminz e prepa jp .< ches asm a ane 
Pulveris oryzz sative, aa % j 
M. et ft pulvis. 


Use: As a dusting powder in acute erythematous and vesicular eruptions 


78. Pulvis terre cimolea. 
Fuller’s earth, in fine powder, 
R P 


Use: An absorbent application in eczema and intertrigo. 


79. Pulvis magnesti et acidi salicylici. 
R  Magnesii usti, 3v 


sete eee cece cece eeees roe E43 
Pulveris talci venetii, Ss LISS atten cee Clas oe ee 67775 
Acidi salicylici, gr. Xij... 1... ese eee eee ee ceee fel 
Balsamiurperivia ne Clts x spice 4 is sh tee Eansioras cee 80 


M. et ft. pulvis. 


Use: An absorbent and astringent application in acute erythematous con- 
ditions and hyperidrosis. 


80, Pulvis magnesit carbonaiis. 


Rs Magnesii carbonatis levis,.. 
Pulveris lycopodii, 44 %ss........ on hee ate ene 15|55 
M. et ft. pulvis. 


Use: Asa dusting powder in erythematous eczema. 


81. Pulvis antipruriticus. 
KR Chloralis hydratis, 


Complione: aa Bi 1 ne eo ae 
Rub together until liquid, and incorporate with | 
Pulveris amyli,--.)- ol fe seein @ eis bi caaiets 31\10 


M. Keep tightly corked in a wide-mouthed bottle. 
Use: A powerful antipruritic, to be well rubbed in with the hand 


82. Pulvis camphore et zinci. 
KR OPulveris camphore, 3ss— 3j 


Sees hey A I9o4— 3/88 
LS AMCUIORIN GAY Shs cece PAM a tcl 1555 | 
Pulveris amyli, Bids Ceter CRM A os a od 31,10 


M et ft. pulvis. 
UsrE: As a dusting powder to relieve pruritus, 


THERAPEUTICS OF DISEASES OF THE SKIN 293 


UNGUENTA. 


In the preparation of ointments too much care 
cannot be exercised in reducing tothe finest possible 
state the substances to be incorporated, for more © 
harm than good is often done by having coarse par- 
ticles in an ointment which is to be applied to an 
abraded surface. The physician should, therefore, 
take especial supervision over the preparation of 
ointments, and should frequently inspect those in 
use by the patient. It is well’to first grind down 
any mineral ingredient in a mortar, adding a little 
sweet almond oil, making it into a paste, which is 
then to be added to the excipient. The greatest 
care must also be exercised that the material be per- 
fectly fresh, for the least rancidity of the ointment 
renders it irritating. The preparations of petroleum, 
cosmoline and vaseline meet this requirement, but 
where protection of the part is desired a more solid 
substance is needed, and most of the following pre- 
scriptions are made with the unguentum aque 
rose, U.S. P., a most invaluable aid in the treat- 
ment of skin diseases. Ointments should always be 
spread on cloth, as on the wooly side of lint, when 
the surface is raw; in chronic conditions gain is had 
by rubbing them in. When protection is desired, it 
is well to have new dressings ready spread with the 
ointment before the old ones are removed. 


294 MANUAL OF DISEASES OF THE SKIN. 


83. Unguentum zinc oxidi, 


 eBZ Cie OxIGl Wa sa— Geo et oe Ei eee ss 1'194— + 3/88 
Unenentl agus /TOS2 10s jones cohen 3110 
M. et ft. unguentum. 


Use: Soothing and protective; a drachm of .tincture of camphor or chlo- 
roform may be added, or "from five to fifteen drops of carbolic acid, as an 


antipruritic. 
84. Unguentum calamine, 
BR. Acidi carbolici, gtt. v—xvj....5...5... 32— 1103 
Pulveris calaminz prep., 3ss—3j.... I|94— 3/88 
ZAinict )Oxidl, +3 SS-=5 Geek a eet soe Ij9g4— 388 


Unguentigaquce rosze, ie free sa Sere bee eh SLO 


M. et ft. unguentum. 
Use: Soothing and protective. 


85. Unguentum bismuthi sub-nitratis, 


R Bismuthi sub-nitratis, 3ss—Zij...... 1ljo94— _7(77 
Unguenti aque laurocerasi, 3j....... 31|10 


M. et. ft. unguentum. 
Use: Soothing and mildly astringent. 


86. Unguentum bismuthi (vel zinct) oleatis (Anderson). 


i oe DismuraioXtdd, sxc. es he acs ties sae detale 50 ee gh 
(vel :ZinGl SOXTGI) 73 1.2 sss Tues iat he heed 7177 
A Gidi oleict tac AI: mere es esa ae Mah RA Hey Ee 
Unguenti petrolei, Zijt3 i ela Serpe Arie ES 70 
Cerze albze, SIN) Sngnitrs Ghs'ahte i wert mar Se hehe we soe 
Oletroscey SOV) some cS en Poet sao bahia ata ; 32 


M. Rubup the bismuth (or zinc) oxide with the oleic acid, and let it 
stand for two hours; place in a water bath, add_ the vaseline and 
wax, and when dissolved stir until cold and add the oil of roses. 


Use: Soothing dnd astringent in acute inflammatory conditions. 


87. Unguentum acid tannici. 


Ey WBALCAGIs RAN NUCL UNG Gicis te iegoe wre eas Rtas og oop ace’ > ae cites 
Ungwent-aquce rose, 29 Sie os. = «hi ein ee one - <a ALG 


M. et ft. unguentum. 
Use: Astringent; of especial service in eczema of the scalp and ears. 


THERAPEUTICS OF DISEASES OF THE SKIN. 295 


88. Unguentum picts et since. | 


R Unguenti picis liquide, 3 j—3iij..... 3\/88— 11/66 
ZTCUORIG) eGo ory, Jens «au ws) oie Sidr She's Ij94— 3/88 
Usguenti aqua rose. ad: & fi wie vane on « 31|10 








M. et ft. unguentum. 
Use: Antipruritic and protective ; of especial value in infantile eczema. 


89. Unguentum cadini et zinct. 





ROO lei cadini (ve/ rusci), 3 ss—3]j..-..- 1l94— 3/88 
LANG. OXIUL, SSS— mop tc aeeteew ee Ij94— 388 
Unguenti aquze rose, %j..... ee Pare, eae han ge) | 


M. et ft. unguentum. 
Use: Antipruritic and mildly astringent. 


90. Unguentum picis et hydrargyt. 


BR Liiquoris picis alkalini, 3 j— 3 iij..... 3\88— 11/66 
(See Formula 42.) 
Unguenti hydrarg. ammon., 3ij— 3iv = 7/77— =—15|55 
Unguenti aque rose, ad 2 j Jeers eee 31|10 
M. et ft. unguentum. 


Use: Antipruritic and mildly stimulating; of especial value in psoriasis 
of the scalp. 


gt. Unguentum hydrargyrt et bismuth. 


Ree Bismuthisub-nitratis,: 3 js. wns ees. « a | 
Unguenti hydrarg. ammon., 3 j— 3 iv 88— 15/55 
Unguenti=aques: rose; ad. 3 j.0. os. a 10 | 


M. et ft. unguentum. 
Use: Astringent and slightly stimulating. 


92. Unguentum hydrargyrt nitratis. 


R —Unguenti hydrargyri ae 3j—3iij 3/88— 11/66 
Unguentiy aque rose, eg 3}... wae 31)10 
Olen geranily ctta-V sedis itete a ce now re 28 
M. et ft. unguentum. 
Use: Mildly stimulating in chronic eczema. 


93. Unguentum hydrargyrt oxidt rubri. 


KR Unguenti hydrarg. oxidirub., 3 j— 3 iij bh, 11/66 
Unguenti aque rose, ad Zj geete see 31/10 | 

M. et ft. unguentum. i 

Use: Mildly stimulating in chronic eczema. 


296 ‘“MANUAL OF DISEASES OF THE SKIN. 


94. Unguentum diachyi, (Hebra’s Didchylon ointment). 


BRO lei olivarum optimi, 3% xv...... on Ete Te ae 466/54 
Phin broxidi,’S 11s Sieve ges Pee oo Sere ines 116/62 
Oleiitdvandulee, Saja. Se ee eee eee ee 6/75 


M. Add the oil to two pounds of water and heat it with constant stir- 
ring ; the litharge is to beslowly sifted in while it is well stirred, 
fresh water being added asrequired. The ointment is to be stirred 
until cold and the lavender then added. In winteraslightly larger 
quantity of oil is required to make a soft ointment. 


Use: Astringent and soothing, but irritating to some skins in acute conditions. 


95. Unguentum diachyli modificatum. 


i eEmplastri diachylt,<.s00p sche Seni sah ee ; 
Vaseline 04, 52 4.25. siueer ah ete se PND a cio 5 Mipans ot 


M. Dissolve with heat, and stir until cold. 
Use: Astringent and soothing in subacute eczema. 


96. Unguentum hydrargyst cum pluméo (Startin). 


at @ Pharmnbi! acetatis; 4.46% 9p cet enete ates ae Wcend lege 
Hydrargyri chloridi mitis, 44 gr. x............ 164 
CADE OXIGEEL © Othe tant terre Someetans Freie ie - 
Unguenti hydrargyri nitratis, 4a Dj .......... 1|29 
AGIBISPrECENntic. fon awe ays vnisierg Niemen Om fa 
Olei palmee rectificati, aa io. ae Lcd sie 15/55 


M. et ft. unguentum. 
UsE: Moderately stimulating ; much used in England in eczema capitis. 


97. Unguentum plumbi et stramonit, 


BRB CLiquoris plumbi subacetatis see Bor 3/75 
Acidi fannicif Dj iaiceecs oe vas PUR 6 Rahs hs sms 1\29 
Unguenti stramonii, 3 j....0..sseeeeee Cl SO LILO 


M. et ft. unguentum. 
Use: Astringent and soothing ; of especial value in external hemorrhoids. 


98. Unguentum acidi chrysophanict. 
-R  Acidi chrysophanici, 3 ss—3ij......-- © 1194— 7/77 
Unguenti aque rose, %j....+... setter Bio 


M. Dissolve with heat and stir until cold. 


Use: Powerfully stimulating and irritant to many skins; of especial value 
in psoriasis and ringworm. 





THERAPEUTICS OF DISEASES OF THE SKIN. 297 


99. Unguentum acidi pyrogallici. 
R_ Acidi pyrogallici, j— 3 ij..... Ura a 7/75 
Unauenti aquacsrosae. 0% jira... as st 31! 10 


M. Dissolve with heat and stir until cold. 


Use: Moderately stimulating in weakest, caustic in greatest strength; of 
especial value in psoriasis and ringworm. 


100. ee he styracis et sulphurts, 








Eure OLY TACIS MOICIS ait. 1)y. mae os ern rh as IO 
Unguenti sulphuris, ‘3 ij—3iv........ 9 7/77-— 15/55 
UinSienti Petrolel Gee Vovcitenstess ers. © 31|10 
M. et ft. unguentum, ; 
Use: Anti-parasitic and moderately stimulating, for scabies. 
101. Unguentum sulphuris compositum, 
(Modified Wilkinson’s ointment.) 
BR Sulphuris sublimati,....... CE AAS PIE eae me 
CSU eatin dame) seuss heel Coes oes ois face tin'y N77 
Crete, preparatee, 5 -1jSee 1p eit. ea ee Pid ce bPerotens win O74 
WAPOISEVATICISs. i's Sa fuse es ans A ee a 
URGUIMSg AA GT rerel's ia sfetiotat sche e) 4 aban = ce aetctnmes we) SEL LO 
M. et ft. unguent. 
Use: A rather stimulating remedy for scabies. 
102. Unguentum hydrargyri et olet ruset. 
BA OIE tuscls Sse tes was eke tae fe »  2|50— [5 
Unguenti hydrarg. oxidi rub.,3j—3iij 3/88—11/66 
Unguenti aque ros, ad Zj......... PL Lal Ce 








M, et ft. unguentum. 


Use; Mildly stimulating and anti-parasitic, in chronic eczema and ring- 
worm, 


103. Unguentum hydrargyri et todinit, 





BR Unguenti hydrargyri,....... ate trate steers /s Pies 
Agen ficial COULD... 2.76 deta cae, 3s BS TR vy 
Unguenti diachyli (Formula 94) 44 %ss........ 15/55 


Misce intime. 


Use : Powerfully stimulant ; to be rubbed well into the skin over syphilitic 
indurations and bone lesions, 


298 MANUAL OF DISEASES OF THE SKIN. 


104. Unguentum acidi carbolict. 





BR * Acidt carbolici, 0 j— 5 i355 102s es eee es 1j29— 7/77 
Glyceriti amyli (Formula 24) 
(vel unguenti petrolei), Ziv......... 124/41 


M. et ft, unguentum. 
Use; Antipruritic, to be used freely to the body, especially after alkaline 


baths. 
105. Unguentum anti-pruriticum. 
Gunn Cam phorees sine oes cae ciate oe : 
Chloralis hydratis, 4a 3 j—3ij....... 3/88— 7/77 
Rub together until a liquid results, then add 
Slowly-svith Triction, -t%". sin. ss<5 wes 
Unguenti aque rose, 3j..... a iso <n * 3110 


M. et ft. unguentum. 
Use: Powerfully antipruritic ; if applied where the surface is abraded it causes 
burning and irritation. 


106. Unguentum picis et belladonne. 


BR . Unguenti picis liquids, 3 vj. 5... «0.0 9 weer 23/32 
Ungeuentibelladonna, 16 vie s.ce osc te es ean 15/55 
J ancturas: aconitis 3: jy «sous se sk ene eee eens be 3/75 
LINC “ORIG, <5 Lae ws Ghee wie SA low oietafele airs 7177 
Ung uemtltaguce £0520, )oewi- ese eeein ee eis ee 23}32 


M. et ft. unguentum. 
UsE: Hew ettully antipruritic ; of especial service in pruritus and eczema of the 
vulva. 


107. Unguentum sulphuris hypochloridt. 











RK Sulphuris hypochloridi, 3 j— 3 ij....... 3|88— 4/77 
Extracti rumicis rad. 3 ij— 3 iv....... 7\77— 15155 
Unguenti aque rose, 13 j.00...'. enone: 5LIeO 

M. et ft. unguentum. 

Use; Stimulating and absorbent, in acne indurata. 
108. Solutio hydrargyri. 

RK Hydrargyri chloridi corrosivi, gr. iv......... = 25 
CSI VCETITIZ:, His nmr beens ei eye ee re eae Sree a ate 3/88 
Agus destillatie2s'wij.. hicae Aare Selnios wine a0 Wiss 27\21 

M. 


Use; For hypodermic injection in syphilis; twelve drops contain one tenth 
of a grain of mercury. 


INDEX. 


ABORTION, syphilis a cause of, 127. 
Abscesses of the skin, 204 (141). 
Absorption by the skin, 16. 
Acarus or steatozoon folliculo- 
rum, 76. 
Acarus scabiei, 68. 
Accuracy of diagnosis in skin 
disease, 2, 34, 35. 
Achorion Schénleinii, 46, 56. 
Achroma, or leucoderma, 236. 
Acne albida, 76. 
disseminata, 78. 
indurata, 73, 78, 79. 
juvenilis, 78. 
mentagra, 157. 
molluscum, 73, 76 (247). 
nigra, 75. 
papulosa, or simplex, 73, 78. 
punctata, 73, 75, 76. 
rosacea, 73, 78, 79 (137, 
174, 175). 
sebacea cerea, 74. 
sebacea cornea, 74. 
sebacea oleosa, 73, 74. 
simplex, 73, 78. 
~ vulgaris, 78. 
causes Of, 13, 80, 81. 
diagnosis of, 80 (51, 109, 
137, 159, 247). 
frequency of, 29, 3I. 
treatment of, 75, 81, 82, 83. 
Acquired achroma or leucoderma, 
236. 
Adenopathy, 9, 120. 


Addison’s disease, 212, 214. 
Age, influence of, on the produc- 
tion of skin diseases, 45. 
Air, effect of, in eczema, 186. 
Albinismus, 235. 
Alopecia, 239-242. 
areata, 239, 241. 
furfuracea, 200. 
idiopathic, 240. 
symptomatic, 239. 
syphilitica, 239. 
vulgaris, 239. 
Alphos, 195. 
Aneesthesia cutis, 90, 99. 
Anesthetic leprosy, 260. 
Analgesia, 9g. 
Analysis of 8000 cases of skin 
disease, 25. 
Anatomy of the skin, 4, 
Angioma, or telangiectasis, 256. 
Anidrosis, 85. 
Aniline, dermatitis from, 189. 
Animal parasitic affections, 63. 
Anthrax, 201, 203. 
Anus, eczema of the, 180. 
Aphthous stomatitis, diagnosis 
from mucous patches, 126. 
Applications, method of making, 
in eczema, 186. 
Area Celsi, 241. 
Argyria, 214. 
Arms, eczema of the, 176, 177. 
Arnica, dermatitis from, 18g. 
Arrectores pilorum, 12, 13. 


299 


300 
Arrectores pilorum, connection 
with acne, 13. 
Arsenic, dermatitis from, 189. 
Artificial eruptions, 72, 189, I9gI. 
Atrophia cutis, 237, 238. 
pilorum propria, 243. 
senilis, 238. 
Atrophy of corium, 237. 
of hair, 238. 
of nail, 244. 
of pigment, 235. 
pof skin, 237,°238. 
Atropine in mercurial salivation, 
142. 
Auditory canal, eczema of the,174. 
Avoidance of certain kinds of food 
in skin disease, 271, 272, 273. 


BAKER’S itch, or eczema of the 
hands, 176. 

Balanitis, diagnosis from chan- 
croid, 207 ; from herpes, 152, 

Baldness, idiopathic, 240. 

symptomatic, 239. 
syphilitic, 239. 

Balnea, 275. 

Bandage, rubber, in eczema of the 
legs, 179. 

Barbadoes leg, 227. 

Barber’s itch, 50. 

Baths in skin diseases, 276. 

Baths, mercurial, in syphilis, 130. 

Baths, Turkish, harm from, 97, 
274, 276. 

Beard, ringworm of the, 50. 

Belladonna eruption, diagnosis 
from roseola, 139. 

Belladonna in mercurial saliva- 
tion, 132. 

Birth-mark, 256. 

Black-heads, 75. 

Black measles, 102 (108, 210), 

Black small pox, 108, 210. 

Blanching of the hair, 237. 

Bleb, 36, 37. 


_| Broad 


INDEX. 


Blood-vessels of the skin, 7. 

Bloody sweat, 210. 

Body louse, 61. 

Boils, 201. 

Breasts, eczema of the, 181. 

Bricklayer’s itch, or eczema of the 
hands, 176. 

condyloma, 
patches, 125, 222. 

Bromides, eruption from, 195, 267. 

Bromidrosis, 86. 

Bronzed-skin disease, 214. 

Bruises, diagnosis from erythema 
nodosum, I4I. 

Brushes, tooth, syphilis transmit- 
ted by, 11g. 

Buboes, 9. 

Bucnenia tropica, 227. 

Bulle, 20, 37, 153. 

Bullous eruptions, 122, 153, 154. 

Burmese ringworm, 52. 


or mucous 


CALLOSITAS, callus or callosity, 
220. 

Cancer of the skin, 262 (124, 248). 

Canities, 235, 237. 

Carbuncle, 203. 

Carcinoma cutis, 262 (124, 248). 

Causes of skin diseases, 42. 

Caustics, 278. 

Cauterization of chancres, I29. 

Chafing or intertrigo, 189. 

Chancre, 118, 120, 129 (207). 

extra-genital, 11g. 

Chancroid, 118, 207. 

Chaps or fissures in eczema, 169. 

Charbon, 133. 

Cheiro-pompholix, 88, 156, 157. 

Cheloid, 246. 

Chicken-pox, III, I12, I13. 

Chinese ringworm, 52. 

Chloasma, 212, 213 (31, 61, 125, 
253,256, 236). 

Choleric roseola, 139. 

Chromidrosis, 86, 87. 


INDEX. 


Chromophytosis, 60. 

Chylopoiétic viscera, importance 
of attention to in skin diseases, 
8I. 

Cicatrical keloid, 246. 

Cicatrix, 36, 40. 

Cingulum, go. 

Circumcision, syphilis transmitted 
during, TIg. 

Claret stain, 255. 

Classification of skin diseases, 18. 

Clavus, 216, 219. 

Clothes louse or body louse, 63. 

Cnidosis, 142. 

Coffee, effect in skin diseases, 
271, 

Cold sores, 151. 

Color of skin, 7. 

Comedo, 75, 76. 

Condylomata, 125, 222. 

Confluent small-pox, 108. 

Congestive seborrheea, 249. 

Congestion in eczema, 167. 

Connective tissue, hypertrophies 
of, 223. 

Constipation, 56, 80, 81, 185, 207, 
269. 2 

Constitutional causes, 43, 44. 

Contagious impetigo, I61. 

Copaiba eruption, 12I, 139, IQI. 

Corium, 6, 

atrophy of, 237. 
Corns, 219. 
Cornu cutaneum, 216, 218. 
humanum, 218. 

Corpuscles, tactile, 8. 

Cosme’s paste, 278. 

Couperose, 79. 

Crab louse, 65. 

Crabs, 65. 

Cracks, or fissures, 36, 39, 169. 

Croton oil, dermatitis from, 189. 

Crust& lactea, or milk crust, 164, 
168, 182. 


301 


Crusted ringworm, 56. 
Cuniculus, the, in scabies, 68, 69. 
Cutaneous horns, 216, 218. 
Cuticle, structure of, 7. 
Cutis anserina, 13. 

pendula, 229. 

variegata, 236. 

vera, 6, 
Cysts, sebaceous, 77. 


DANDRUFF, or dandriff, 74, 200. 
Dartos of the scrotum, 9. 

Death from varnishing skin, 14. 
Debility a cause of baldness, 240. 
in eczema, 184. 

Definition of terms, 36. 
Degeneratio unguium, 244. 
Demodex folliculorum, 76. 
Depilation, 50, 55, 59, 60. 
Depilatories, 232. 
Derma, 6. 
Dermatalgia, 90, 98. 
Dermatitis, 188. 
calorica, 188. 
contusiformis, I40. 
exfoliativa, 193. 
gangreenosa, 189. 
medicamentosa, Igo. 
traumatica, 188. 
venenata, 188, 189. 
Dermatology, on the study of, I. 
relations to medi- 
cine, 3. 
Dermatolysis, 223, 229. 
Dermatosclerosis, 223. 
Dermatosyphilis, 120. 
Desquamative dermatitis, 193. 
Diagnosis, 32. 
Diet, definition of the term, 268. 
errors of, causing skin dis- 
- ease, 81, 97, 267. 
in eczema, 186, 269. 
Diphtheritis cutis, 135. 
Discoloration of the skin, 38, 212. 


Crusts, occurrence of, 35, 38, 168. | Distribution of eruptions, 33. 


302 


Drinking utensils, syphilis trans- 
mitted by means of, IIg. 

Dry tetter, 195. 

Dyes causing eruptions, 189. 

Dysidrosis, 87, 157, 177. 

Dyspepsia in skin disease, 82, 
184, 240, 269. 

Dystrophia cutis, 90, 99. 


EARS, eczema of the, 174. 
Eating tetter, or lupus, 249. 
Eating utensils, syphilis trans- 
mitted by means of, IIg. 
Ecthyma, 157, 162. 
Ecthyma, syphilitic, 122. 
Eczema, 164-188, 
acute, 170. 
chronic, 17I. 
dry, 175. 
erythematosum, 172. 
fendillé, 173. 
fissum, 171, 173. 
impetiginosum, 171, 172. 
infantile, 182, 183. . 
madidans, 168, I7I, 173, 
178: 
marginatum, 52, 180. 
moist, 175. 
papulosum, 171, 172. 
pustulosum, I7I, 172. 
rimosum, 171, 173. 
rubrum, 171, 173. 
sclerosum, 171, 173. 
squamosum, 171, 173 (74, 
168). 
vesiculosum, 171, 172. 
causes of, 184, 185. 
congestion in, 167. 
cracks of, 169. 
crusting in, 168. 
definition of 42, 165. 
diagnosis of, 174, 175, 
£70;577,-178,.179, 160 
(48, 50, 51, 53, 58, 61, 
65, 66, 80, 88, 122,123, 





INDEX. 


Eczema, diagnosis of, 126, 136, 
141, 144, 147, 149, 152, 
155, 159, 194, 197,207, 
210, 217, 228, 250,264). 
diet in, 269. 
exudation in, 168, 175. 
frequency of, 28, 165. 
infiltration in, 168. 
itching of, 166, 167. 2 
location of, 174, et seg. 
of the anus and genital _ 
region, 180. 
of the auditory canal, 174. 
of the breasts, 181. 
of the eyelids, 174. 
of the ears, 174. 
of the face, 174. 
of the feet and legs, 178, 
of the hands and arms, 
£70,31'77. 
of the lips, 174. 
of the scalp, 174. 
of the trunk, 181. 
papules in, 167. 
pruritus in, 96. 
stages of, 170. 
statistics of, 28, 165. 
thickening in, 168. 
varieties of, 169, 170. 
vesicles in, 167. 
Eggs or nits of pediculi, 64. 
Elasticity of the hair, 11. 
Electrolysis, 233, 257. 
Elephantiasis Arabum, 223, 227. 
Greecorum, 258 (196, 
227, 236). 
Elephant leg, 227. 
Emplastra, 279. 
Emplastrum mercuriale, 129, 279. 
Emunctory function of the skin, 5. 
Endemic verrugas, 229. 
Ephelis, 213. 
Ephidrosis, 84. 
cruenta, 210. 
Epidemic roseola, 103. 


INDEX. 


Epidermal hypertrophies, 216. 
Epidermis, 6, 
Epilation, 50, 55, 59, 60. 
Epithelial cancer, 258, 263. 
Epithelial nests, 264. 
Epithelioma, 258, 263 (182, 250, 
252, 254, 255). 
Equinia, 134. 
Errors of diet in eczema, 269. 
Eruption, definition of, 42. 
Hruptions, artificial, 72, 189, IgI. 
caused by dyes, 189. 
feigned, 87, Igl. 
Eruptive fevers, 101. 
Erysipelas, 135. 
migrans, 135. 
vaccinal, 115. 
bullee in, 155. 
diagnosis of, 136 (141, 
174, 175, 203). 
Erythema, 138, 139. 
annulare, 140. 
iris, 140. 
marginatum, 140. 
multiforme, 140, 154. 
nodosum, I39-I4I. 
papulatum, 140. 
simplex, 139, 140. 
tuberculatum, 140. 
vesiculosum, 140. 
diagnosis of, 141 (105, 
T21, 137, 147, 152,174, 
175, 177, 210, 250). 
varieties of, 139, 140. 
Erythematous eczema, I71, 172. 
eruptions, 138. 
lupus, 249. 
scrofulide, 249. 
syphilis, 120. 
Etiology of skin diseases, 42. 
Exanthemata, 20, IOT. 
Exanthematous nature of syph- 
His,“ Er7: 
Excessive sweating, 84, 
Excoriatio, 36, 39. 


ac3 


Excoriations 36, 39, 63. 
Excretory function of the skin, 
Rote, 
Exfoliative dermatitis, 193. 
dermatitis, diagnosis of, 


194. 
External causes of skin diseases, 


Extra-genital chancres, II9. 
Exudation in eczema, 167. 
Exudative affections, IOI. 
Eyelids, eczema of the, 174. 


FACE, eczema of the, 174. 
Facial herpes, I5I. 
False measles, or rétheln, 103. 
Family tendencies a cause of skin 
disease, 44, 45. 
Farcy, 135. 
Fatty tissue, new formation of, 
248. 

Favus, 56. 

diagnosis of, 58, 59 (176, 

197). 
Febrile herpes, 150, I51. 
Febris urticata, 142. 
Feet, eczema of the, 178. 
Feigned eruptions, 87, IgI. 
Females, skin diseases in, 30. 
Fermented liquors, 271. 
Fever sores, I5I. 
Fibroma, 245, 246. 
lipomatodes, 247. 

Filaria sanguinis, 228. 
Fish-skin disease, 216. 
Fissura, 36, 39, 169. 
Fluxus sebaceus, 73. 
Folliculitis pilorum, 157. 
Food in eczema, 269. 
Fragilitas crinium, 239, 243. 
Frambeesia, 223, 229. 
Freckles, 252. 
Frequency of skin diseases, 25-31. 
Furfuraceous alopecia, 200. 
Furrow or cuniculus, 68. 


304 


Furuncular inflammation due to 
vaccination, I15. 
Furuncles, 201. 


GANGRENE of the skin, 188, 189. 
Genital region, eczema of the, 180. 
German measles, 103. 
Giant urticaria, 143. 
Glanders, 134. 
Glands of the skin, I2, 13, 14. 
sebaceous, diseases of, 73. 
sweat, diseases of, 83. 
Glandular affections, 73. 
enlargement in syphi- 
lis, 120. 
Glassblower’s pipe, syphilis trans- 
mitted on, IIg. 
Glossy skin, 99. 
Glycerita, 280. 
Goose skin, 13. 
Gouty state in skin diseases, 184. 
Grayness of hair, 237. 
Grocer’s itch, or eczema of the 
hands, 176. 
Growth of nails, 15. 
Grubs, 75. 
Grutum, 76. 
Gummy syphilis, 124. 
Gutta rosea, 79. 


H_2ZMATIDROSIS, 87, 209, 210. 
209. 
purpura, 209, 210, 
; small pox, 108. 
Hair, atrophy of, 238. 
elasticity of, II. 
follicles, structure of, 10, II. 
gray, 237. 
loss of, 239. 
muscles of, 12. 
papilla, structure of, Io. 
structure of, 10, II. 
Hairs, number of, I1. 
Hairy mole, 214, 231, 233. 
Hands, eczema of, 176, 177. 


INDEX. 


Head louse, 63. 
Heat eruption, or prickly heat, 
146. 
Hebra’s classification of skin dis- 
eases, 20. 
Hemiatrophia facialis, 226. 
Hemorrhagic purpura, 210. 
small pox, 108. 


‘Hereditary syphilis, 117, 127. 


Herpes, 150. 
circinatus, 47, I5I. . 
facialis, I51. 
febrilis, 150, T5I. 
généralisé fébrile, 151. 
gestationis, 150, 152. 
iris, 150, 151, 154. 
labialis, I51. 
preputialis or progenita- 
His s25Or Tha, Wis 2: 
tonsurans, 49. 
zoster, gO, 150. 
diagnosis of, 
175, 207). 
Hirsuties, 231. 
Hives, 142. 
Honey-combed ringworm, 56. 
Hordeolum, 201, 204. 
Horny excrescence, 218. 
Hydroa, 153 (151, 162). 
Hydro-adenitis, 204. 
Hygiene, 273. 
Hyperzemia, 167. 
Hypereesthesia cutis, 90, 98. 
Hyperidrosis, 84. 
Hypertrichosis, 231. 
Hypertrophiz, 212. 
Hypertrophies of connective tis- 
Sue,.223. 


152 (137, 


of epidermis and 
papille, 216. 
of hair, 231. 
of nails, 233. 
of pigment, 212. 
Hypodermic injections of mercury 
in syphilis, 131. 


INDEX. 


IcHTHYOSIS, 216. 
hystrix, 217. 
Idiopathic baldness, 240, 
Idrosis or hyperidrosis, 84. 
Ignis sacer or zoster, go. 
Impetiginous eczema, I7I, 172. 
Impetigo, 157, 160. 
contagiosa, 157, 161. 
syphilitic, 122. 
diagnosis of, 160 (162, 
163). 
Incubative period of 
TES. 
Individual tendencies, 44, 45. 
Induration of chancre, Iig. 
Infantile eczema, 182, 183. 
syphilis, 127. 
Infiltratio, 39, 168. 
Inflammatory affections of the 
skin, IOI. 
Inherited syphilis, 117, 127, 128. 
Initial lesion of syphilis, 118. 
Injections, hypodermic, of mer- 
cury in syphilis, 131. 
Insensible perspiration, 14. 
Internal causes of skin diseases, 


chancre, 


43. 
Intertrigo, 189 (53). 
Inunction, mercurial, in syphilis, 
130. 
Iodide eruption, I91, 267. 
Iritis, syphilitic, 120. 
Itch, the, 68. 
baker’s, or eczema of the 
hands, 176. 
barber’s, 50. 
bricklayer’s, or eczema of 
the hands, 176. 
grocer’s, or eczema of the 
hands, 176. 
washerwoman’s, or eczema 
of the hands, 176. 
Itching, or pruritus, 94 (70, 96, 
166). 


Ivy, poison, 189. 


305 


KELIS, 246. 

Keloid, 245, 246. 

Keratosis pilaris, 216, 218 (147). 
Kerion, 50, 51, 55. 

Kidneys, relation to skin, 15. 
King’s evil, or scrofuloderma, 253. 
Kiss, syphilis given by, 11g. 


LABIAL herpes, 151. 
Land scurvy, or purpura, 209. 
Lead pencils, syphilis transmittep 
Dy lig. 
‘“Leeting ” surface, 168. 
Legs, eczema of, 178. 
Lentigo, 212. 
Leontiasis, 258. 
Lepra, 196, 258. 
anzesthetica, 260. 
maculosa, 259. 
mutilans, 260. 
tuberculosa, 260. 
vulgaris, 194. 
Willani, 194. 
Leprosy, 258 (226, 236, 261). 
Leucasmus, acquired, 236. 
universalis, 235. 
Leucoderma, 235, 236. 
diagnosis of, 236 (62, 
1255214, 201). 
Leukoplakia, 126. 
acquisita, 236. 
congenital, 235. 
Lice, body, 63. 
Lichen, 145, 146. 
agrius, 146, 
circumscriptus, 146. 
pilaris, 147, 218. 
ruber planus, 146. 
scrofulosus, 147. 
simplex, 146. 
syphilitic, I21. 
tropicus, 146. 
urticatus, 143, 146, 148. 
diagnosis of} 147, 148 (71, 
122,141,177, 194,197,207). 


306 


Liniz albicantes, 238. 
atrophice, 238. 
Lipoma, 248. 
diagnosis of, 248 (247). 
Lips, eczema of, 174. 
Liquor picis alkalinus, 284. 
Liver spots, 60, 213. 
Local causes of skin disease, 43. 
Loss of hair, 239. 
Lotions, 281. 
Lousiness, 63. 
Lues, 117. 
Lupus, 249. 
erythematosus, 249. 
exedens, 251. 
hypertrophicus, 251. 
sebaceus, 249. 
syphiliticus, 123, 124, 251. 
tuberculosus, 251. 
vulgaris, 251. 
diagnosis of, 250 (48, 80, 
197, 254, 255, 261, 264). 
frequency of, 30. 
Lymphadeénie cutanée, 257. 
Lymphangioma, 257. 
diagnosis of, 248, 


257. 
tuberosum mul- 
tiplex, 257. 


Lymphatic new formations, 257. 
Lymphatics of the skin, 8. 
Lymph scrotum, 228. 


MACUL&, 20, 36. 
atrophice, 238. 
Macular leprosy, 259. 
syphilis, 120. 
Malaria, 97, 143, 184. 
Males, skin diseases in, 30. 
Malignant pustule, 133, 134. 
Matrix of the nail, 15. 
Measles, 3, IOI, 102, 103. 
black, 108, 2I0. 
diagnosis of, 102, 103 
(105, 109, 113). 


INDEX. 


Measles, German, 103. 

Medicinal eruptions, 188, Igo. 

Melanoderma, 212, 213, 2106. 

Melanotic cancer, 262. 

Mentagra, 157. 

Mercurial salivation, treatment of, 
132. 


ee vapor baths in syphilis, 


130. 
Mercury, hypodermically, in yee 
ilis, 131; 
in syphilis, 128, 130, I3I. 
Method of applying ointments, 
186,418959.203, 
Microsporon Audouini, 241. 
furfur, 60. 
Miliaria, 89. 
Milium, 75, 76. 
Milk crust, 164, 171, 172. 
in skin disease, 271. 
Mixtures, 286. 
Mixed treatment in syphilis, 131. 
Moist eczema, 175. 
papules or mucous patches, 
125, 264. 
tetter, 164. 
Mole, hairy, 214, 231, 233. 
pigmentary, 214, 215. 
Mollities unguium, 244. 
Molluscum contagiosum, 76, 77. 
fibrosum, 246, 
pendulum, 246. 
sebaceum, 76, 77. 
simplex, 246. 
Morbilli, ror. 
Morbus Addisonii, 212, 214. 
pedicularis, 63. 
Morpheea, diagnosis of, 225, 226 
(236, 261 
Ope able 
frequency of, 30. 
Moth patches, or chloasma, 213. 
Mother’s mark, 255, 256. 
marks, or nzevi, 214, 255. 
Mucous patches, 125. 


INDEX. 


Mucous patches, diagnosis of, 126 
(152; 3175, 181; 222, 262). 
Multiform eruptions, 164. 
Muscles of the hair follicles, 12. 
Muscular fibres of the skin, struc- 
ture of, 9. 
Mycosis, 230. 
fungoide, 231. 


NAVUS araneus, 256, 257. 
flammeus or nevus vascu- 
losus, 255, 256. 
pigmentosus, 212, 214. 
pilosus, 214, 231, 233. 
sanguineus, 255. 
spilus or nevus pigmen- 
tosus, 214. 
vasculosus, 255, 256. 
verrucosus, 215. 

Nails, atrophy of, 244. 
hypertrophy of, 233. 
structure of, 14, 15. 

Neoplasmata, 245. 

Nerves, new formations of, 258. 

of the skin, 8. 

Nesselsucht, 142. 

Nettle rash, 142. 

Neuroma cutis, 258. 

Neuroses, 90. 

New formations, 245. 

Nitrate of silver discoloration, 214. 

Nits of pediculi, 64, 65. 

Nodes, syphilitic, diagnosis from 

erythema, I4I. 

Noli me tangere, 251, 264. 

Nomenclature of skin diseases, 18. 

Non-parasitic sycosis, 157 (175). 

Number of hairs, 11. 

Nursing, syphilis communicated 


by, TIg. 


“ 


OAK, poison, 189. 
Occupation, influence of, in the 
production of skin diseases, 45, 


274. 


307 


Oily seborrhcea, 73. 
Ointments, 293. 

mode of applying in 

eczema, 186, 187. 

Onychatrophia, 244. 
Onychauxis, 234. 
Onychia, 205, 206. 
Onycho-gryphosis, 234. 
Onycho-mycosis, 205. 
Osmidrosis, 86. 


PACHYDERMIA, 227. 
Pacihian corpuscles, or tactile cor- 
puscles, 8. 
‘*Paget’s disease,” 182. 
Painful subcutaneous 
258 
Palmar syphilis, 126. 
Panniculus adiposus, 6. 
Papilla, hair, structure of, 10. 
Papillary layer of the skin, 6. 
hypertrophies, 216. 
Papular eruptions, 145. 
Papule, 20, 37. 
moist, or mucous patch, 
125. 
Parasitic diseases, 46-72. 
sycosis, 50 (51, 157). 
sycosis, diagnosis of, 175. 
Parchment skin, xeroderma, or 
ichthyosis, 216. 
Pars papillaris, 6. 
Patches, mucous, 12\ (264). 
Pediculosis, 63. 
Pelade, 241. 
Peliosis rheumatica, 210. 
Pencils, syphilis transmitted by, 
I1Q: 
Pemphigus, 153, 154. 
cacheticus, 155. 
foliaceus, 154. 
gangreenosus, 155. 
malignus, 155. 
pruriginosus, I55. 
syphiliticus, 122, 128. 


tubercle, 


308 


Pemphigus vulgaris, 154. 
diagnosis of, 155 (194, 
261). 


frequency of, 30. 
Perspiration, insensible, 14. 
Phlegmonous eruptions, 201. 
Phthiriasis, 63. 

capitis, 64. 

corporis, 63. 

pubis, 65. 


diagnosis of, 65, 66, | 


67, 68(70, 160, 175, 
180). ' 


frequency of, 29. 
Phyma, 36, 38. 
Physiology of the skin, 15. 
Pian, 229. 
Piebald skin, 236. 
Pigmentary atrophies, 235. 
hypertrophies, 212. 
mole, 214, 215. 
nevus, 212, 214. 
syphiloderm, 124, 125. 
Pigment of the skin, 7. 
Pills, 289. 
Pimples of acne, 78. 
“*Pitting” of small-pox, 
ment of, II0. 
Pityriasis, 74. 
capitis, 193, 200. 
maculata et circinata, 
194. 
pilaris, 218. 
rubra, 182, 193, 217. 
versicolor, 60. 
diagnosis of, 197 (51, 
74, 176, 182, 217). 
Plantar syphilis, 126. 
Plaques muqueuses, 125. 
Plasters, 279. 
- Pointed condyloma, 222. 
‘ Poison ivy, 189. 
oak, 189. 
sumac, 189. 
Polytrichia, 231. 


treat- 


INDEX. 


Pompholix, 156 (88, 153). 
Pomphus, 36, 37. 


‘Porcupine men, 217. 


Porrigo, 162. 
decalvans, 241. 
favosa, 56, 


Port wine marks, 255. 


Powders, 290. 
Poxsr iy, 
Predisposition to skin affections, 
45. 
Pregnancy, influence on the skin, 
44, 239. 
Preputial, 
I5I. 
Prickly heat, 146. 
Primary lesion of syphilis, 120. 
lesions of the skin, 35. 
Prurigo, 145, 148. F 
podicis, 148, 180. 
scroti, 148, 180. 
diagnosis of, 66, 149. 
pruritus in, 96. 
Pruritus, 90, 94 (66, 148). 
ani, 95. 
hiemalis, 95. 
scroti, 95. 
senilis, 95. 
vulvee, 95. 
diagnosis of, 96 (66, 71). 
Psoriasis, 74, 193, 194. 
aggregata, 196. 
buccalis, 126. 
circinata, 196. 
diffusa, 196. 
gyrata, 196. 
inveterata, 196. 
nummularis, 196. 
orbicularis, 196. 
punctata, 196. 
syphilitica, 126. 
diagnosis of, 197 (48, 
50, 51, 59, 65, 66, 74, 
$22,106. Tag Types, 
182,194, 197, 207,250). 


or progenital herpes, 


INDEX. 


Psoriasis, frequency of, 30. 
pruritus in, 96. 

Purples, 209. 

Purpura, 209. 
hemorraghica, 209, 210. 
rheumatica, 209, 210. 
simplex, 209. 
variolosa, 210. 

: frequency of, 30. 

Pustule, 20, 36, 37. 
Pustula maligna, 133. 
Pustular eczema, 175. 


QUANTITY of fluid daily excreted 
by the skin, 14. 
Quinine eruption, T90, 267. 


RECURRENT exfoliative dermatitis, 
194. 
Red gum, or lichen simplex, 146. 
Removal of superfluous hairs, 232. 
Rete malpighil, 7. 
mucosum, 7. 
Rhagades or fissures, 36, 39. 
Rheumatic purpura, 209, 210. 
Rhinoscleroma, 249, 255. 
Rhus toxicodendron, 189. 
venenata, 189. 
Ringworm, 47. 
Burmese, 52. 
crusted, 56. 
honeycombed, 56. 


Tokelau, 52. 
diagnosis of, 48, 50, 
51, 53. 


frequency of, 29. 

Rodent ulcer, 263. 

Rosacea, 257. © 

Roseola, 138. 
gestiva, 139. 
annulata, 139. 
autumnalis, 139. 
cholerica, 139. 
epidemic, 103. 
infantilis, 139. 


309 


Roseola, syphilitic, 120, 139. 
vaccinia, 139. 
variolosa, 139. 
diagnosis of, 139. 
Rose rash, or roseola, 139. 
Rétheln, 103 (121). 
Rougeole, IoT. 
Rubber bandage.in eczema of the 
legs, 179. 
Rubeola, 101. 
diagnosis of, I02, 103, 
(121). 
Running tetter, or eczema, 164. 
Rupia, syphilitic, 123. 


SALICYLIC acid, eruption from, Igo. 
Salivation, treatment of mercurial, 


1392; 
Salt rheum, 164. 
Sapo viridis, 284. 
Sarcoma cutis, 258, 265. 
Sarcoptes scabiei, 68. 
Scabies, 68. 
diagnosis of, 70 (66, 88, 
144, 147, 149, 160, 163, 
L77 PUI Ops ISTH Se. 
207). 
frequency of, 30. 
over-treated, 72. 
Scale, 36, 38. 
Scall, 164. 
Scalled head, or milk crust, 164. 
Scalp, eczema of, 174. 
Scaly tetter, 195. 
Scarf skin, structure of, 7. 
Scar, 36, 39. 
Scarlatina, 3, 104. 
Scleroma, 223. 
neonatorum, 223, 227. 
Scleriasis, 223. 
Scleroderma, 223. 


diagnosis of, 224 
(177, 225, 226, 
261, 263). 


frequency of, 30. 


310 


Scorbutus, 209, 211. 
diagnosis from pur- 
pura, 210. 
Scratching, causing skin lesions, 
63, 69, 167. 
Scrofulide erythemateuse, 249. 
tuberculeuse, 251. 
Scrofuloderma, 249, 253. 
Scurvy, 211. 
land, 209. 
Sebaceous cysts, 77. 
glands, anatomy of, II. 
glands, diseases of, 73. 
glands, secretion from, 
; I2. 
Sebiparous glands, II, 12. 
Seborrhagia, 73. 
Seborrheea, 73, 200. 
congestiva, 249. 
diagnosis of, 73, 74 
(50, 51, 62, 176, 197, 
250, 264), 
Sebum, I2. 
Secondary lesions, 35. 
’ Segars, syphilis transmitted by, 
II9Q. 
Senile atrophy of the skin, 238. 
Sex in skin diseases, 30, 45. 
Shingles, go. 
frequency of, 30. 
Skin, anatomy of, 5. 
atrophy of, 237, 238. 
grafting and syphilis, I19. 
diseases, analysis of 8,000 
cases of, 125. 
Small-pox, 107. 
Spargosis or elephantiasis Arabum, 
227, 260. 
Spiritus saponis kalinus, 284. 
Spitze condylom, 222. 
Spots or macules, 36. 
Squame, 20, 35, 38. 
Squamous eruptions, 193. 
Stains, 36, 38. 
St. Anthony’s fire: term applied 


INDEX. 


to erysipelas, 135, and herpes, 
150. 
Starch, iodide of, in syphilis, 132. 
Statistics of 8000 cases of skin dis- 
ease, 25. 
Steatorrheea, 73. 
Steatozoon folliculorum, 76, 
Stimulants in skin disease, 271. | 
Sterility caused by syphilis, 127. 
Strize atrophice, 238. 
Strophulus albidus, 76. 
prurigineux, 149. 
Struma, 253. 
Structure of the skin, 5, 6. 
Styes, 204. 
Subcutaneous connective tissue, 6. 
painful tubercle, 258. 
Sudamina, 89. 
Sudoriparous glands, 13. 
Sumac, poison, 189. 
Sunburn, 213. 
Superfluous hairs, 231. 
Supra-renal melasma, 214. 
Sweat, bloody, 87, 211. 
glands, action of, 14. 
glands, anatomy of, 13. 
glands, diseases of, 83. 
glands, number of, 13, 14. 
Sweating excessive, 84. 
colored, 86, 87 
offensive, 86. 
Sycosis, 157. 
parasitica, 50. 
diagnosis of, 
175). 
Symptoms in diagnosis, 32. 
Syphilis, 117. 
vaccinal, II4. 
diagnosis of, I2I, 126 
(48, 50, 51, 58, 65, 66, 
_ 80, 139, 147, 159, 160, 
a 163, 174, 176, 177, 179, 
181, 182, 202,210, 214, 
230, 236, 250, 254, 255, 
261, 264). 


159 (51, 


INDEX. 


311 


Syphilis, exanthematous nature of | Tinea unguium, or onycho-myco- 


£17; 
Syphilis, frequency of, 29. 
initial lesion of; 118. 
length of treatment of, 
132: = 
modes of transmission of, 
LE7p EO: 
Syphilitic alopecia, 239. 
gumma, diagnosis from 
lipomata, 248. 
lupus, 123, 124, 251. 
mucous patches, diag- 
nosis from eczema, 
175. 
onychia, 206. 
roseola, 120, 139. 
Syphiloma, 124. 


TACTILE corpuscles, 8. 

Tar wash, alkaline, 284. 

Tattooing, syphilis conveyed by, 
IIg. 


Tea in skin disease, 271. 
Telangiectasis, 256. 
Tetter, dry or scaly, 195. 
Tetter, moist, 164. 
Therapeutics of 
275, 
Thickening, or infiltration, 36, 39, 
168. 

Tinctura, or stain, 36, 38. 
Tinea barbz, 50. 

capitis, 49. 

circinata, 47. 

corporis, 47. 

cruris, 51. 

decalvans, 241. 

favosa, 56. 

furfuracea, 60. 

kerion, 50, 51. 

sycosis, 50. : 

tondens, 49. ; 

tonsurans, 49. 


trichophytina, 47, 50. 


skin diseases, 





sis, 205. 
versicolor, 60. 
diagnosis of, 48, 50, 51, 53, 
58, 59, 61 (175, 176, 180, 
182, 194, 197, 242). 
Tissue, adipose, 6. 
Tokelau ringworm, 52. 
Tooth brushes, syphilis transmit- 
ted by EQ: 
Toys, syphilis 
IQ. 

Transmission of syphilis, modes 
CI Lips uo. 

Trichauxis, 231. 

Trichophyton tonsurans, 29, 46. 

Trichophytosis, 49. 

Trichorexis nodosa, 239, 243. 

Trichorrheea, 239. 

Trophic nerves of the skin, 8. 

Tubercle, subcutaneous painful, 
258. 

Tubercula, 36, 38. 

Tubercular leprosy, 260. 

Tumor, 36, 38. 

Tyloma, 220. 

Tylosis, 216, 219, 220. 


transmitted by, 


ULCER, 36, 40, 205, 206. 
rodent, 263. 
Ulcus, simplex, 206. 
venereum, 207. 
Unilateral atrophy of the face. 
226. 
Urticaria, 138, 142. 
acute, 143. 
chronic, 143. 
bullosa, 154. 
papulosa, 143. . 
pigmentosa, 144. 
tuberosa, 143. 
diagnosis of, 144 (71, 
I2I, 141, 147, 149). 
frequency of, 30. 


312 


VACCINAL erysipelas, I15. 
roseola, 139. 
syphilis, 114. 
Vaccination, I13. 
safety of, 113-116. 
syphilis communi- 
cated by, I19, 


furuncular inflamma-- 


tion due to, II5. 

Vaccinia, I13. 
Vapor baths, mercurial, in syphi- 

lis, 130. 

baths, when harmful, 276. 

Varicella, III. 
Variola, 107. 

maligna, 108. 

modificata, 108. 
Variolous purpura, 210, 

roseola, 139. 

Vaso-motor nerves of the skin, 8. 
Vegetable parasites, 2 
Vegetations, 222 (126). 
Venereal ulcer, 207. 

warts, 222 (126). 
Verruca, 216, 221. 

acuminata, 221, 222. 

necrogenica, 221, 222. 

senilis, 221. 

vulgaris, 221. 
Verrugas, endemic, 229. 





INDEX. 


Versicolor, pityriasis or tinea, 


60. 
Vesicula, 20, 36, 37. 
Vitiligo, 236. 
Vitiligoidea, 247. 
Vilemingkx’ solution, 283. 


WARTS, 221-229. 

Washerwoman’s -itch, or eczema 
of the hands, 176. ; 

Water, effect of, in eczema, 186, 

in skin disease, 275. 

Watering or “‘ leeting ” surface in 
eczema, 168. 

Wens, 77. 

Wheal, 36; 37. 

Wilkinson’s ointment, 297. 


XANTHELASMOIDEA, 144. 

Xanthoma, 245, 247. 
multiplex, 248. 
planum, 247. 
tuberosum, 247. 

Xeroderma, 85, 86, 217. 


YAWS, 229. 
ZONA, 90, I50. 


Zoster, go. 
frequency of, 30. 


BULKLEY. Archives of Dermatology. A 
QUARTERLY- JOURNAL OF SKIN AND VENEREAL DiIs- 
EASES. Edited by L. Duncan BuLKLEyY, A.M., M.D., 
Attending Physician for Skin and Venereal Diseases at the 
New York Hospital, Out-Patient Department ; late Physi- 
cian to the Skin Department, Demilt Dispensary, New 
York, etc. Price, per year, $4.00; specimen copies, $1.00 


The aim of the ARCHIVES OF DERMATOLOGY has been 
and shall still be to meet the wants of the general prac- 
titioner, and to serve as a communication between the 
specialist, whose entire attention is devoted to skin and 
venereal diseases, and those in general practice, that the 
daily-gained experience of the latter may reach the 
former. 

The ARCHIVES OF DERMATOLOGY is now ¢he only Sct- 
entific Fournal published in the English language devoted 
exclusively to skin and venereal diseases, and is of service 
to every practitioner. 

With a view of furnishing simple- matter in each issue 
of immediate practical advantage to the general prac- 
titioner, the editor will endeavor, as space permits, to 
give, as in the past, plain comments on common diseases 
of the skin in the form of serial articles. 

The digest department will continue, as before, to 
epitomize the current literature of the day by means of 
the able staff of collaborators, who have already so faith- 
fully and earnestly aided the Journal. 


OPINIONS OF THE ‘' ARCHIVES,” 

‘* This journal, under Dr. Bulkley’s management, continues to be conducted 
with much spirit. It containsnot only original papers which represent most of 
the dermatological work done in the States, but excellent abstracts of all Eu- 
ropean work in this department.’’—London Practitioner. 


‘““ In every sense a credit to American literature.””—Medical Record. 


““* The Archives of Dermatology ’ is not only the only journal in the English 
language devoted to the specialty of skin diseases, but, it may be safely said, 
is unequalled by any similar journal, French, Italian, or German. The num- 
bers before us present an excellent example of a journal which, while contain- 
ing scientific matter for the specialist, also furnishes practical information for 
the general practitioner. Here the practitioner may find what it is impossible 
to getin any text-book,—from the circumstances of the case,—a varied armory, 
from which he can draw weapons for every emergency. We can cordially 
recommend this journal to the general reader as a special journal which is not 
for specialists only.”’—Philadelphia Medical Times. 


G. P. PUTNAM’S SONS, Publishers, New York. 


BULKLEY. Eczema and its Management. 
A Practical Treatise Based on the Analysis of Two 
Thousand Five Hundred Cases of the Disease. By L. 
Duncan BULK LEY, A.M., M.D., Physician for Skin 
and Venereal Diseases at the New York Hospital, Out- 
Patient Department, etc. Price, . ee Tr ets: 


‘‘ The whole work is fascinatingly interesting, and we recommend it 
to the general practitioner, for whom it is chiefly written, as a most 
valuable guide to the intelligent treatment of one of the most fre- 
quent as well as troublesome of skin affections. * * * In regard 
to treatment, he enters most minutely into details. * * * The 
chapter on diet and hygiene is equally comprehensive. A formulary 
is also appended.” —Pitladelphia Medical and Surgical Reporter. 


‘* Every general practitioner should read this book, that-he may 
know how to cure eczema.” —American Specialist. 


‘‘The book is a clear guide. It is practical, simple, direct in 
style, logical in arrangements, and exhaustive in the treatment of the 
subjects. It cannot fail to extend the reputation of its distinguished 
author.” —Piiladelphia Medical Times. 


‘“‘ In every sense it is a good book, worthy of the most careful study 
' by every member of the profession, general practitioner or specialist.” 
—Detroit-Lancet. 

‘‘This book is one of the most valuable contributions to medical 
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‘* A work which, in good faith, teaches the physician of average 


intelligence how to bring such cases to a successful issue. * * * 


Any physician who sees one case of eczema per annum can afford 
to buy and study this valuable book. It is a model of what a medical 
monograph should be, uniting the thoroughness of the German in- 
vestigator with the practical acumen of the American practitioner.” 
— St. Louis Clinical Record. 


G. P. PUTNAWM’S SONS, Publishers, 
New York. 











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——“‘éPPTT 


